Healthcare Provider Details

I. General information

NPI: 1124408745
Provider Name (Legal Business Name): MARC SURDYKA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 MARENGO ST HRA-102
LOS ANGELES CA
90033
US

IV. Provider business mailing address

11 EAGLE ROCK AVE STE 201
EAST HANOVER NJ
07936-3167
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-1200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: