Provider Demographics
NPI:1861883472
Name:ANOTADO JR, NICASTOR (PT)
Entity type:Individual
Prefix:
First Name:NICASTOR
Middle Name:
Last Name:ANOTADO JR
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 1:23500 S PATUXENT BEACH RD
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-4213
Mailing Address - Country:US
Mailing Address - Phone:954-822-4304
Mailing Address - Fax:
Practice Address - Street 1:11100 ASBURY CIR
Practice Address - Street 2:
Practice Address - City:SOLOMONS
Practice Address - State:MD
Practice Address - Zip Code:20688-3004
Practice Address - Country:US
Practice Address - Phone:410-394-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24389225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD215304Medicare Oscar/Certification