Healthcare Provider Details

I. General information

NPI: 1114320744
Provider Name (Legal Business Name): ANGELA MARIE GEREZ-MARTINEZ AYSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA MARTINEZ

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

972 MESA VIEW ST
UPLAND CA
91784-8000
US

IV. Provider business mailing address

3908 10TH ST
RIVERSIDE CA
92501-3522
US

V. Phone/Fax

Practice location:
  • Phone: 909-973-3856
  • Fax:
Mailing address:
  • Phone: 951-274-7744
  • Fax: 951-274-7754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number41356
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT41356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: