Provider Demographics
NPI:1508746751
Name:SUPKO, THOMAS JR
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SUPKO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-2001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:266 HARRISTOWN RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3302
Practice Address - Country:US
Practice Address - Phone:201-445-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-06
Last Update Date:2025-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02366300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty