Healthcare Provider Details

I. General information

NPI: 1205384484
Provider Name (Legal Business Name): MAX ESPOSITO PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E TERRY DR
POCATELLO ID
83209-0001
US

IV. Provider business mailing address

1400 E TERRY DR ROOM 202
POCATELLO ID
83209-0001
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-2590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT-4787
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: