Provider Demographics
NPI:1891768198
Name:MANFREDI, MARK (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MANFREDI
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 1:600 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876
Mailing Address - Country:US
Mailing Address - Phone:978-452-3453
Mailing Address - Fax:978-452-2652
Practice Address - Street 1:600 CLARK RD
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876
Practice Address - Country:US
Practice Address - Phone:978-452-3453
Practice Address - Fax:978-452-2652
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY65292Medicare ID - Type Unspecified