Provider Demographics
NPI:1881460830
Name:BALTAZAR, KEITH DOMINIC GALINO (DPT)
Entity type:Individual
Prefix:DR
First Name:KEITH DOMINIC
Middle Name:GALINO
Last Name:BALTAZAR
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 1:247 NEPTUNE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-1711
Mailing Address - Country:US
Mailing Address - Phone:201-736-3501
Mailing Address - Fax:
Practice Address - Street 1:2625 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5606
Practice Address - Country:US
Practice Address - Phone:908-686-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02226700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist