Healthcare Provider Details

I. General information

NPI: 1518066901
Provider Name (Legal Business Name): THOMAS DEAZA MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11252 SW 152ND PL
MIAMI FL
33196-4369
US

IV. Provider business mailing address

5760 SW 11TH ST
WEST MIAMI FL
33144-5108
US

V. Phone/Fax

Practice location:
  • Phone: 305-388-7702
  • Fax: 305-260-9764
Mailing address:
  • Phone: 305-215-8084
  • Fax: 305-260-9764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-18830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: