Healthcare Provider Details

I. General information

NPI: 1306115621
Provider Name (Legal Business Name): SAMY S TADROS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 MASON AVE
DAYTONA BEACH FL
32117-4690
US

IV. Provider business mailing address

1075 MASON AVE
DAYTONA BEACH FL
32117-4690
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4596
  • Fax: 386-257-0558
Mailing address:
  • Phone: 386-255-4596
  • Fax: 386-257-0558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305209874
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number031785
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT30815
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30815
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: