Provider Demographics
NPI:1194777102
Name:ESTOMO, ELDEBRANDO ORCULLO (PT)
Entity type:Individual
Prefix:
First Name:ELDEBRANDO
Middle Name:ORCULLO
Last Name:ESTOMO
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 1:29 PORT MERCER RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-1341
Mailing Address - Country:US
Mailing Address - Phone:609-520-8647
Mailing Address - Fax:
Practice Address - Street 1:186 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850-1418
Practice Address - Country:US
Practice Address - Phone:732-418-0004
Practice Address - Fax:732-545-1185
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00613400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097255PV7Medicare ID - Type Unspecified