Provider Demographics
NPI:1386786432
Name:FADULLON, JOSEPH DONAYRE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DONAYRE
Last Name:FADULLON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 CLUBHOUSE ST
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-2119
Mailing Address - Country:US
Mailing Address - Phone:906-748-0183
Mailing Address - Fax:630-759-6873
Practice Address - Street 1:386 CLUBHOUSE ST
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-2119
Practice Address - Country:US
Practice Address - Phone:906-748-0183
Practice Address - Fax:630-759-6873
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007885225100000X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP18780002Medicare ID - Type Unspecified