Healthcare Provider Details

I. General information

NPI: 1093815532
Provider Name (Legal Business Name): BRIAN WESLEY GUPTON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 A1A N STE 18A
PONTE VEDRA BEACH FL
32082-3220
US

IV. Provider business mailing address

PO BOX 48116
JACKSONVILLE FL
32247-8116
US

V. Phone/Fax

Practice location:
  • Phone: 904-778-7501
  • Fax: 904-778-7504
Mailing address:
  • Phone: 904-725-1657
  • Fax: 904-725-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT19848
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: