Healthcare Provider Details

I. General information

NPI: 1083750764
Provider Name (Legal Business Name): PTR SPORTS, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 CIVIC CENTER DR SUITE 25
SANTA CLARA CA
95050-7301
US

IV. Provider business mailing address

1825 CIVIC CENTER DR SUITE 25
SANTA CLARA CA
95050-7301
US

V. Phone/Fax

Practice location:
  • Phone: 408-404-4700
  • Fax: 408-404-4701
Mailing address:
  • Phone: 408-404-4700
  • Fax: 408-404-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY G BLUE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 408-404-4700