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General NPI Number Information
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NPI Number | 1578752549
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Entity Type | Individual
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Provider Name | GUSTAVO J. MEDOSKY L.M.T.
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Gender | Male
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Dates
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Enumeration Date | 10/16/2007
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Last Update Date | 11/28/2018
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Provider Practice Location Address
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Address Line | 205 SW 84TH AVE
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City | PLANTATION
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State | FL
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Zip | 33324-2708
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Country | US
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Telephone | 954-536-0767
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Fax |
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Provider Business Mailing Address
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Address Line | 6681 SW 20TH ST
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City | PLANTATION
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State | FL
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Zip | 33317-5104
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Country | US
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Telephone | 954-536-0767
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA19949
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA27822
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License Number State | FL
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