Healthcare Provider Details

I. General information

NPI: 1669622437
Provider Name (Legal Business Name): PETER KOFITSAS MS,PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 RIVERVALE RD
RIVERVALE NJ
07675-6122
US

IV. Provider business mailing address

792 RIVERVALE RD
RIVERVALE NJ
07675-6122
US

V. Phone/Fax

Practice location:
  • Phone: 201-637-3258
  • Fax: 201-391-0580
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberQA009227
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: