Provider Demographics
NPI:1356051908
Name:ORDANIEL, RUSTOM JOHN A (DPT)
Entity type:Individual
Prefix:
First Name:RUSTOM JOHN
Middle Name:A
Last Name:ORDANIEL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 CENTERVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4376
Mailing Address - Country:US
Mailing Address - Phone:401-737-4581
Mailing Address - Fax:
Practice Address - Street 1:535 CENTERVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4376
Practice Address - Country:US
Practice Address - Phone:401-737-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT03386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist