Provider Demographics
NPI:1285093807
Name:BLANK, ALEXANDER MATTHEW (DPT)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:MATTHEW
Last Name:BLANK
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 1:1445 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870
Mailing Address - Country:US
Mailing Address - Phone:203-731-7075
Mailing Address - Fax:
Practice Address - Street 1:1445 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870
Practice Address - Country:US
Practice Address - Phone:202-745-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist