Provider Demographics
NPI:1063588770
Name:MCDIVITT, JOSEPH BENJAMIN (MPT)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:BENJAMIN
Last Name:MCDIVITT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 CHIPPEWA TRAIL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:08055
Mailing Address - Country:US
Mailing Address - Phone:609-714-8594
Mailing Address - Fax:856-227-5716
Practice Address - Street 1:1652 COOPER STREET
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096
Practice Address - Country:US
Practice Address - Phone:856-227-5312
Practice Address - Fax:856-227-5716
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00558000225100000X
PAPT007512L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ024973Medicare ID - Type Unspecified