Provider Demographics
NPI:1316823776
Name:DISPOTO, ETHAN W (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:W
Last Name:DISPOTO
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RINGWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07456-2028
Mailing Address - Country:US
Mailing Address - Phone:973-600-3147
Mailing Address - Fax:
Practice Address - Street 1:200 SANFORD RD
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:ME
Practice Address - Zip Code:04090-5534
Practice Address - Country:US
Practice Address - Phone:973-600-3147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT9602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer