=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396484929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WITHERSPOON JR. MPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2022
-----------------------------------------------------
Last Update Date | 06/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3315 SE 31ST ST
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-6209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-598-7008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3023 E FORT KING ST
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34470-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-598-7008
-----------------------------------------------------
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 | PT18759
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------