=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619535259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KETZIEL ESTRADA DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2019
-----------------------------------------------------
Last Update Date | 05/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2202 W OAK AVE
-----------------------------------------------------
City | PLANT CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33563-7222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-754-3761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1226 E CUMBERLAND AVE UNIT 120
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33602-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-608-3490
-----------------------------------------------------
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 | PT33977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------