Healthcare Provider Details

I. General information

NPI: 1982102877
Provider Name (Legal Business Name): ONDREY TOBIAS ISAAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 N HAIRSTON RD
STONE MOUNTAIN GA
30083-2871
US

IV. Provider business mailing address

1908 AVENUE N
FORT PIERCE FL
34950-2055
US

V. Phone/Fax

Practice location:
  • Phone: 772-828-6370
  • Fax:
Mailing address:
  • Phone: 772-828-6370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCL1259854
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: