Healthcare Provider Details

I. General information

NPI: 1497961114
Provider Name (Legal Business Name): CHRISTODOULOS A FYSENTZOU PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 EAGLE ROCK AVE
WEST ORANGE NJ
07052-2994
US

IV. Provider business mailing address

108 STILES ST APT. # 2
ELIZABETH NJ
07208-1885
US

V. Phone/Fax

Practice location:
  • Phone: 973-669-0078
  • Fax: 973-669-1113
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01245300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: