Provider Demographics
NPI:1104870773
Name:ROTELLA, MARK A (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ROTELLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NEWTOWN RD # A
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4194
Mailing Address - Country:US
Mailing Address - Phone:203-739-0765
Mailing Address - Fax:203-739-0792
Practice Address - Street 1:1001 WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-1314
Practice Address - Country:US
Practice Address - Phone:401-434-1773
Practice Address - Fax:401-435-0500
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI02006225100000X
CT007027225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1114979226OtherAETNA
CT1114979226OtherANTHEM
CT1114979226OtherCIGNA
RI007058120Medicare UPIN
CT1114979226OtherAETNA