Provider Demographics
NPI:1871651067
Name:TANTORSKI, EDWARD JR (PT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:TANTORSKI
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3506
Mailing Address - Country:US
Mailing Address - Phone:203-384-8681
Mailing Address - Fax:
Practice Address - Street 1:1931 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3506
Practice Address - Country:US
Practice Address - Phone:203-384-8681
Practice Address - Fax:203-384-0722
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist