Healthcare Provider Details

I. General information

NPI: 1780063768
Provider Name (Legal Business Name): MARISA GOPAUL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2015
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W D. L. INGRAM AVENUE BLDG. 1408 CANNON AFB
CANNON AFB NM
88101
US

IV. Provider business mailing address

4900 SW 46TH CT APT 1001
OCALA FL
34474-6271
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-2778
  • Fax:
Mailing address:
  • Phone: 352-433-1918
  • Fax: 352-433-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT30177
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: