MEDICARE: JOSEFINA DUMAGAT FULLERTON

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
1	225100000X	Physical Therapist	PT11716	FL

General Provider Information

NPI Number	:	1942405030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEFINA DUMAGAT FULLERTON

Provider Business Mailing Address
First Line	:	1406 AMBASSADOR DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33764-2522
Country	:	US
Telephone Number	:	727-524-6955
Fax Number	:

Provider Business Practice Location Address
First Line	:	2770 REGENCY OAKS BLVD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-1509
Country	:	US
Telephone Number	:	727-791-1500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	07/08/2007

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