Provider Demographics
NPI:1104930908
Name:KAWAS, JOHN C (PT)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:KAWAS
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 1:655 BELLE TERRE RD
Mailing Address - Street 2:APART 55
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1960
Mailing Address - Country:US
Mailing Address - Phone:631-974-0026
Mailing Address - Fax:
Practice Address - Street 1:655 BELLE TERRE RD
Practice Address - Street 2:APART 55
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1960
Practice Address - Country:US
Practice Address - Phone:631-974-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020893-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6697169OtherGHI
NYQC0221Medicare ID - Type Unspecified
NYP14334Medicare UPIN