Provider Demographics
NPI:1881837557
Name:KO, MARY E (DPT)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:KO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 2ND AVE
Mailing Address - Street 2:PO BOX 319
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1141
Mailing Address - Country:US
Mailing Address - Phone:973-256-0330
Mailing Address - Fax:973-812-0339
Practice Address - Street 1:194 2ND AVE
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1141
Practice Address - Country:US
Practice Address - Phone:973-256-0330
Practice Address - Fax:973-812-0339
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01025800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist