Provider Demographics
NPI:1730410663
Name:CASUPANG, SEDRIC (PT)
Entity type:Individual
Prefix:
First Name:SEDRIC
Middle Name:
Last Name:CASUPANG
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 1:10509 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2014
Mailing Address - Country:US
Mailing Address - Phone:718-441-3211
Mailing Address - Fax:718-441-3744
Practice Address - Street 1:10509 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2014
Practice Address - Country:US
Practice Address - Phone:718-441-3211
Practice Address - Fax:718-441-3744
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
031206-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031206-1OtherLICENSE NUMBER