Provider Demographics
NPI:1780396176
Name:ILAO, MARK ANTHONY SOSA (PT)
Entity type:Individual
Prefix:
First Name:MARK ANTHONY
Middle Name:SOSA
Last Name:ILAO
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 1:8415 BRITTON AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2455
Mailing Address - Country:US
Mailing Address - Phone:201-844-5458
Mailing Address - Fax:
Practice Address - Street 1:737 COMMACK RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-7407
Practice Address - Country:US
Practice Address - Phone:631-388-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist