Provider Demographics
NPI:1619487444
Name:PETRACCO, VINCENT GARY (DPT)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:GARY
Last Name:PETRACCO
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 1:2 WORLDS FAIR DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-1369
Mailing Address - Country:US
Mailing Address - Phone:732-537-0909
Mailing Address - Fax:732-564-9032
Practice Address - Street 1:4810 BELMAR BLVD
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07753-6952
Practice Address - Country:US
Practice Address - Phone:732-938-5333
Practice Address - Fax:732-938-5680
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01741300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01741300OtherBOARD OF PHYSICAL THERAPY