Provider Demographics
NPI:1902029242
Name:FORMISANO, MICHAEL (PT, DPT, OCS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FORMISANO
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3-18 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4727
Mailing Address - Country:US
Mailing Address - Phone:201-887-2409
Mailing Address - Fax:
Practice Address - Street 1:1029 TEANECK RD STE 2E
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4514
Practice Address - Country:US
Practice Address - Phone:551-246-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01081900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ110521Medicare PIN