Provider Demographics
NPI:1891746038
Name:BODIONGAN, CHARO BALAGTAS
Entity type:Individual
Prefix:
First Name:CHARO
Middle Name:BALAGTAS
Last Name:BODIONGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4017
Mailing Address - Country:US
Mailing Address - Phone:973-652-8959
Mailing Address - Fax:973-582-9288
Practice Address - Street 1:45 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2323
Practice Address - Country:US
Practice Address - Phone:973-931-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00960400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097973U0MMedicare ID - Type Unspecified