Healthcare Provider Details

I. General information

NPI: 1306105507
Provider Name (Legal Business Name): DONALD BALLESTEROS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VALLEY RD STE 101
WAYNE NJ
07470-3528
US

IV. Provider business mailing address

11 ACKERMAN AVE
AIRMONT NY
10901-7119
US

V. Phone/Fax

Practice location:
  • Phone: 973-595-7500
  • Fax: 973-595-7770
Mailing address:
  • Phone: 917-495-7597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01048800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: