Provider Demographics
NPI:1881628709
Name:RELIGIOSO, ERSON PAUL III (DPT)
Entity type:Individual
Prefix:DR
First Name:ERSON
Middle Name:PAUL
Last Name:RELIGIOSO
Suffix:III
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 1:6029 PINEHURST CT
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:NY
Mailing Address - Zip Code:14085-9203
Mailing Address - Country:US
Mailing Address - Phone:716-980-5686
Mailing Address - Fax:
Practice Address - Street 1:6029 PINEHURST CT
Practice Address - Street 2:
Practice Address - City:LAKE VIEW
Practice Address - State:NY
Practice Address - Zip Code:14085-9203
Practice Address - Country:US
Practice Address - Phone:716-980-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02071718Medicaid
NY837712OtherMANAGED PHYSICAL NETWORK
NY9310992OtherIHA
NY00011174501OtherUNIVERA
NY000626077001OtherBC/BS
NY6699290OtherGHI
NY000626077001OtherBC/BS