Provider Demographics
NPI:1295979151
Name:JONG, VIDA (MSPT)
Entity type:Individual
Prefix:MS
First Name:VIDA
Middle Name:
Last Name:JONG
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 E 34TH ST
Mailing Address - Street 2:APT. 2D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4943
Mailing Address - Country:US
Mailing Address - Phone:917-309-0417
Mailing Address - Fax:
Practice Address - Street 1:292 MADISON AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6307
Practice Address - Country:US
Practice Address - Phone:212-418-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019406-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics