Provider Demographics
NPI:1396129037
Name:KOKULAK, BRIAN (DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KOKULAK
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 1:532 LAFAYETTE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-4411
Mailing Address - Country:US
Mailing Address - Phone:973-940-0423
Mailing Address - Fax:973-940-0399
Practice Address - Street 1:540 LAFAYETTE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3497
Practice Address - Country:US
Practice Address - Phone:973-940-8680
Practice Address - Fax:973-940-8634
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01606100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist