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NPI Code Detail

MEDICARE: BRIAN WESLEY GUPTON DPT

MEDICARE: BRIAN WESLEY GUPTON DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical TherapistPT19848FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1Y0578OTHERFLBCBS

General Provider Information

NPI Number : 1093815532
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIAN WESLEY GUPTON DPT
Provider Business Mailing Address
First Line : PO BOX 48116
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32247-8116
Country : US
Telephone Number : 904-725-1657
Fax Number : 904-725-7247
Provider Business Practice Location Address
First Line : 880 A1A N
Second Line : STE 18A
City : PONTE VEDRA BEACH
State : FL
Zip : 32082-3220
Country : US
Telephone Number : 904-778-7501
Fax Number : 904-778-7504
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/24/2006
Last Update Date : 07/09/2007

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Directions to “ BRIAN WESLEY GUPTON DPT” Practice Location

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