Healthcare Provider Details

I. General information

NPI: 1164528451
Provider Name (Legal Business Name): DOUG DUSTIN BUETHE MPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 E BRANDON BLVD
BRANDON FL
33511-5509
US

IV. Provider business mailing address

3903 NORTHDALE BLVD STE 111W
TAMPA FL
33624-1864
US

V. Phone/Fax

Practice location:
  • Phone: 813-413-5513
  • Fax: 813-681-8300
Mailing address:
  • Phone: 813-381-6778
  • Fax: 440-815-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22852
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: