MEDICARE: ENGELBERT DIZON DE VERA PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1125821	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1125821	OTHER	TX	TEXAS BOARD OF PHYSICAL THERAPY EXAMINERS

General Provider Information

NPI Number	:	1407496359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENGELBERT DIZON DE VERA PT

Provider Business Mailing Address
First Line	:	PO BOX 61160
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78466-1160
Country	:	US
Telephone Number	:	361-884-2904
Fax Number	:	361-884-2919

Provider Business Practice Location Address
First Line	:	5113 SPRING BROOK DR
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78413-5629
Country	:	US
Telephone Number	:	361-248-2004
Fax Number	:	888-499-1749

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2020
Last Update Date	:	01/08/2020

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Directions to “ ENGELBERT DIZON DE VERA PT” Practice Location

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