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General NPI Number Information
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NPI Number | 1619439551
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Entity Type | Individual
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Provider Name | GREGORY GORDON SODEMAN
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Gender | Male
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Dates
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Enumeration Date | 04/01/2019
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Last Update Date | 04/01/2019
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Provider Practice Location Address
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Address Line | 311 NE 8TH ST
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City | HOMESTEAD
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State | FL
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Zip | 33030-4738
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Country | US
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Telephone | 305-248-8600
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Fax |
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Provider Business Mailing Address
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Address Line | 29858 SW 159TH DR
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City | HOMESTEAD
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State | FL
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Zip | 33033-3307
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Country | US
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Telephone | 305-505-5333
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA20367
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License Number State | FL
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