Provider Demographics
NPI:1063249449
Name:PEDERSEN, ROBERT EDWARD (DPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 STELTON RD STE 209
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-5344
Mailing Address - Country:US
Mailing Address - Phone:848-297-3747
Mailing Address - Fax:
Practice Address - Street 1:1630 STELTON RD STE 209
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-5344
Practice Address - Country:US
Practice Address - Phone:848-297-3747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02274300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist