Provider Demographics
NPI:1881680742
Name:MASCILAK, GARY J (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:MASCILAK
Suffix:
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 1:21 LAFAYETTE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871
Mailing Address - Country:US
Mailing Address - Phone:973-729-0291
Mailing Address - Fax:973-729-6710
Practice Address - Street 1:540 LAFAYETTE RD ROUTE 15 SO
Practice Address - Street 2:SUITE B
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871
Practice Address - Country:US
Practice Address - Phone:973-940-8680
Practice Address - Fax:973-940-8634
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00455100111N00000X
NJ40QA00611400208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8380406Medicaid
NJ034356Medicare ID - Type Unspecified
NJ8380406Medicaid