MEDICARE: MR. DAVID VRSALOVIC P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA01116800	NJ
2	171100000X	Acupuncturist	25MZ00084600	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3695912	OTHER	NJ	AETNA HMO PROVIDER #
2	11314607	OTHER	NJ	CAQH ID #
3	P3544996	OTHER	NJ	OXFORD PROVIDER #
4	7996424	OTHER	NJ	AETNA PPO PROVIDER #
5	2254500	OTHER	NJ	UNITED HEALTH PROVIDER #

General Provider Information

NPI Number	:	1134264732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID VRSALOVIC P.T.

Provider Business Mailing Address
First Line	:	552 VALLEY RD
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07043-1805
Country	:	US
Telephone Number	:	973-509-0827
Fax Number	:	973-509-0877

Provider Business Practice Location Address
First Line	:	552 VALLEY RD
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07043-1805
Country	:	US
Telephone Number	:	973-509-0827
Fax Number	:	973-509-0877

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	10/24/2011

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