Healthcare Provider Details

I. General information

NPI: 1861120792
Provider Name (Legal Business Name): MARIO MEJIA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MERRICK RD
LYNBROOK NY
11563-2621
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 516-599-8734
  • Fax:
Mailing address:
  • Phone: 914-294-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number050011
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: