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General NPI Number Information
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NPI Number | 1982102877
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Entity Type | Individual
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Provider Name | ONDREY TOBIAS ISAAC
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Gender | Male
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Dates
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Enumeration Date | 01/25/2018
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Last Update Date | 01/25/2018
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Provider Practice Location Address
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Address Line | 971 N HAIRSTON RD
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-2871
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Country | US
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Telephone | 772-828-6370
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Fax |
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Provider Business Mailing Address
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Address Line | 1908 AVENUE N
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City | FORT PIERCE
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State | FL
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Zip | 34950-2055
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Country | US
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Telephone | 772-828-6370
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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 | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | CL1259854
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License Number State | FL
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