Healthcare Provider Details

I. General information

NPI: 1922158484
Provider Name (Legal Business Name): PABLO EDGARDO DER BOGHOSSIAN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CORTEZ RD W STE C
BRADENTON FL
34207-1335
US

IV. Provider business mailing address

PO BOX 5887
SARASOTA FL
34277-5887
US

V. Phone/Fax

Practice location:
  • Phone: 941-870-7473
  • Fax: 941-870-4915
Mailing address:
  • Phone: 941-870-7473
  • Fax: 941-870-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT13467
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0013467
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: