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NPI Code Detail

MEDICARE: WILSON DIEZ PT, DPT

MEDICARE: WILSON DIEZ PT, DPT
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
1225100000XPhysical Therapist40QA01827700NJ

General Provider Information

NPI Number : 1316414923
Entity Type Code : Individual
Provider Name (Legal Business Name) : WILSON DIEZ PT, DPT
Provider Business Mailing Address
First Line : PO BOX 5261
Second Line :
City : SOMERSET
State : NJ
Zip : 08875-5261
Country : US
Telephone Number : 732-486-9809
Fax Number :
Provider Business Practice Location Address
First Line : 15 BLOOMFIELD AVE
Second Line :
City : MONTCLAIR
State : NJ
Zip : 07042-4888
Country : US
Telephone Number : 973-744-2770
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/01/2018
Last Update Date : 03/18/2020

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Directions to “ WILSON DIEZ PT, DPT” Practice Location

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