Provider Demographics
NPI:1962787085
Name:DISLA, LEONARD R (DPT)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:R
Last Name:DISLA
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 1:246 INDUSTRIAL WAY W
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-4240
Mailing Address - Country:US
Mailing Address - Phone:732-455-2724
Mailing Address - Fax:
Practice Address - Street 1:246 INDUSTRIAL WAY W
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-4240
Practice Address - Country:US
Practice Address - Phone:732-455-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA013498002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic