Provider Demographics
NPI:1255442034
Name:CODNER, LARRY (PT)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:CODNER
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 1:116 HAMPTON GRN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1739
Mailing Address - Country:US
Mailing Address - Phone:718-238-0598
Mailing Address - Fax:718-351-2269
Practice Address - Street 1:116 HAMPTON GRN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1739
Practice Address - Country:US
Practice Address - Phone:718-238-0598
Practice Address - Fax:718-351-2269
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0145431261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP0171Medicare ID - Type Unspecified