Provider Demographics
NPI:1174773626
Name:FUNG, RAYMOND (MPT)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:FUNG
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:201-488-0488
Mailing Address - Fax:201-343-5325
Practice Address - Street 1:1355 15TH STREET
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024
Practice Address - Country:US
Practice Address - Phone:201-224-8717
Practice Address - Fax:201-224-6381
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18083225100000X
NJ40QA01332900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01332900OtherPT LICENSE