Provider Demographics
NPI:1720693492
Name:JOSOL, KARL MATTHEW CUSTODIO
Entity type:Individual
Prefix:
First Name:KARL MATTHEW
Middle Name:CUSTODIO
Last Name:JOSOL
Suffix:
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 1:11230 OTSEGO ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-3783
Mailing Address - Country:US
Mailing Address - Phone:818-800-9022
Mailing Address - Fax:
Practice Address - Street 1:2579 OCEAN AVE FL 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4552
Practice Address - Country:US
Practice Address - Phone:646-780-0926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist