=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336945500
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEMARCO ANTONIO THOMAS DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2025
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9166 FM 2920 RD STE 375
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375-8996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-336-7501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2659 IMPERIAL GROVE LN
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77385-8325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-505-5862
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1405644
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------