Provider Demographics
NPI:1962538470
Name:NISPEROS, GLENMAR (PT)
Entity type:Individual
Prefix:
First Name:GLENMAR
Middle Name:
Last Name:NISPEROS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MORRIS AVE APT 55
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1431
Mailing Address - Country:US
Mailing Address - Phone:973-704-7756
Mailing Address - Fax:
Practice Address - Street 1:17 ACADEMY ST STE 312
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2934
Practice Address - Country:US
Practice Address - Phone:973-648-6808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA01119400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist