Healthcare Provider Details

I. General information

NPI: 1336508738
Provider Name (Legal Business Name): DIOGO TREVISAN P.T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8585 SUNSET DR SUITE 103
MIAMI FL
33143-3746
US

IV. Provider business mailing address

8585 SUNSET DR SUITE 103
MIAMI FL
33143-3746
US

V. Phone/Fax

Practice location:
  • Phone: 305-274-3311
  • Fax: 305-274-1411
Mailing address:
  • Phone: 305-274-3311
  • Fax: 305-274-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT31195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: