=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861751786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDY GATPO MARTINEZ PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2012
-----------------------------------------------------
Last Update Date | 01/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4363 AMBOY RD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-677-5336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 LEVERETT AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10308-1724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-736-5790
-----------------------------------------------------
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 | 032417
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------