Provider Demographics
NPI:1669400289
Name:KERESTAN, MARK (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KERESTAN
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 1:812 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-1664
Mailing Address - Country:US
Mailing Address - Phone:724-929-5774
Mailing Address - Fax:724-929-9524
Practice Address - Street 1:812 BROAD AVE
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-1664
Practice Address - Country:US
Practice Address - Phone:724-929-5774
Practice Address - Fax:724-929-9524
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006525L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA251570641OtherTAX ID
PA0015935850006Medicaid
PA0015935850006Medicaid