Provider Demographics
NPI:1871549923
Name:DEPRIMO, MICHAEL JOHN (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:DEPRIMO
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 1:1530 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2265
Mailing Address - Country:US
Mailing Address - Phone:516-520-3053
Mailing Address - Fax:516-520-5715
Practice Address - Street 1:1530 FRONT ST
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2265
Practice Address - Country:US
Practice Address - Phone:516-520-3053
Practice Address - Fax:516-520-5715
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016321-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ31S61Medicare ID - Type Unspecified