Provider Demographics
NPI:1720138191
Name:ESTOMO, EDILBERTO O JR
Entity Type:Individual
Prefix:
First Name:EDILBERTO
Middle Name:O
Last Name:ESTOMO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020
Mailing Address - Country:US
Mailing Address - Phone:973-361-6054
Mailing Address - Fax:973-361-0272
Practice Address - Street 1:54 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621
Practice Address - Country:US
Practice Address - Phone:201-874-9084
Practice Address - Fax:973-909-7656
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00520400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ096881XJRMedicare PIN
NJ096881WZ3Medicare PIN