Healthcare Provider Details

I. General information

NPI: 1255167136
Provider Name (Legal Business Name): PHILIP MONGELLUZZO III PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 MALCOLM X BLVD
NEW YORK NY
10027-6498
US

IV. Provider business mailing address

6864 YELLOWSTONE BLVD APT A23
FOREST HILLS NY
11375-3330
US

V. Phone/Fax

Practice location:
  • Phone: 212-222-6525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number053069-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: