Provider Demographics
NPI:1861594111
Name:DE LA FUENTE, DAVID (PT, DPT, CSCS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:DE LA FUENTE
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BRANT AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1560
Mailing Address - Country:US
Mailing Address - Phone:732-499-4540
Mailing Address - Fax:732-499-4577
Practice Address - Street 1:77 BRANT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1560
Practice Address - Country:US
Practice Address - Phone:732-499-4540
Practice Address - Fax:732-499-4577
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01170400225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ071361Medicare PIN