=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023765005
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSHUA AMIEL ELIZALDE CASTRO PTRP, PTA, PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2022
-----------------------------------------------------
Last Update Date | 03/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1345 AVENUE OF THE AMERICAS
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-622-6080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 MEETINGHOUSE RIDGE APARTMENT 205
-----------------------------------------------------
City | MERIDEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-622-6080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 045098-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 012312-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------