Basic Information
| Provider Information | |||||||||
| NPI: | 1194710756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DATTILO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, C.PED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 COMMERCE WAY | ||||||||
| Address2: | STE. 120 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038018200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034278066 | ||||||||
| FaxNumber: | 6035010495 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 PORTSMOUTH AVE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | STRATHAM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038852523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037728222 | ||||||||
| FaxNumber: | 6037726738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1866 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3820128 | 01 | NH | AETNA | OTHER | 4353867 | 01 | NH | CIGNA | OTHER | 08Y008079NH01 | 01 | NH | BLUE CROSS BLUE SHIELD | OTHER | 201859513 | 01 | NH | TAX ID | OTHER |