Provider Demographics
NPI:1881810257
Name:PRADO, MARVIN R (PT)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:R
Last Name:PRADO
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 1:230 W JERSEY ST STE L3
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1352
Mailing Address - Country:US
Mailing Address - Phone:908-352-7357
Mailing Address - Fax:908-352-8833
Practice Address - Street 1:654 AVENUE C STE 301
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3899
Practice Address - Country:US
Practice Address - Phone:201-339-4644
Practice Address - Fax:201-339-0056
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00998900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist