Healthcare Provider Details

I. General information

NPI: 1861436131
Provider Name (Legal Business Name): JETHRO ART HERNANDEZ GATDULA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 NE 167TH ST 101
MIAMI FL
33162-3400
US

IV. Provider business mailing address

2815 N COURSE DR 106 B
POMPANO BEACH FL
33069-3075
US

V. Phone/Fax

Practice location:
  • Phone: 305-949-9866
  • Fax: 305-949-4844
Mailing address:
  • Phone: 954-696-3464
  • Fax: 954-970-9291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberPT21281
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT21281
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: