Provider Demographics
NPI:1841574225
Name:UBEDA, VON RYAN MASONGSONG
Entity type:Individual
Prefix:
First Name:VON RYAN
Middle Name:MASONGSONG
Last Name:UBEDA
Suffix:
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 1:12 FENWAY DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-6223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 FENWAY DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-6223
Practice Address - Country:US
Practice Address - Phone:845-206-8048
Practice Address - Fax:845-849-1101
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY62022930225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist