Healthcare Provider Details

I. General information

NPI: 1346578754
Provider Name (Legal Business Name): CARLO PONTI CHAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 W 80TH ST 5TH FL
NEW YORK NY
10024-7608
US

IV. Provider business mailing address

207 W 79TH ST
NEW YORK NY
10024-6283
US

V. Phone/Fax

Practice location:
  • Phone: 212-874-1550
  • Fax: 212-874-1599
Mailing address:
  • Phone: 212-874-1550
  • Fax: 212-874-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0-30011
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: