Healthcare Provider Details

I. General information

NPI: 1063043495
Provider Name (Legal Business Name): FREDERICK WILLIAM TOBER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23123 CAMDEN WAY
CALIFORNIA MD
20619-2446
US

IV. Provider business mailing address

23123 CAMDEN WAY
CALIFORNIA MD
20619-2446
US

V. Phone/Fax

Practice location:
  • Phone: 301-862-5177
  • Fax:
Mailing address:
  • Phone: 301-862-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA5088
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: