MEDICARE: JOHN ROMAN JOHN ROMAN OTR/L

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	225X00000X	Occupational Therapist	016564	NY

General Provider Information

NPI Number	:	1790076123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ROMAN JOHN ROMAN OTR/L

Provider Business Mailing Address
First Line	:	1857 WALTON AVE
Second Line	:	APT 32A
City	:	BRONX
State	:	NY
Zip	:	10453-6230
Country	:	US
Telephone Number	:	347-624-4581
Fax Number	:

Provider Business Practice Location Address
First Line	:	1039 E 241ST ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-1040
Country	:	US
Telephone Number	:	646-335-2334
Fax Number	:

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

Provider Enumeration Date	:	04/19/2011
Last Update Date	:	04/19/2011

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