Healthcare Provider Details

I. General information

NPI: 1427611508
Provider Name (Legal Business Name): MARISUNTA PONTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 WALNUT ST FL 2
PHILADELPHIA PA
19103-5457
US

IV. Provider business mailing address

475 ALLENDALE RD STE 206
KING OF PRUSSIA PA
19406-1495
US

V. Phone/Fax

Practice location:
  • Phone: 215-545-8717
  • Fax: 215-545-9355
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: