Basic Information
| Provider Information | |||||||||
| NPI: | 1578178604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUCOS | ||||||||
| FirstName: | BLAKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 390 ROUTE NJ 10 | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | RANDOLPH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738959925 | ||||||||
| FaxNumber: | 9738959927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2020 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01956200 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.