MEDICARE: MR. GILBERT JEE PON 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	PT 18539	CA
2	225100000X	Physical Therapist	PT18593B	CA

General Provider Information

NPI Number	:	1487739025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GILBERT JEE PON PT

Provider Business Mailing Address
First Line	:	1944 W. GLENOAKS BLVD.
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91201-1644
Country	:	US
Telephone Number	:	818-846-3385
Fax Number	:	818-848-4500

Provider Business Practice Location Address
First Line	:	1944 W. GLENOAKS BLVD.
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91201-1644
Country	:	US
Telephone Number	:	818-846-3385
Fax Number	:	818-848-4500

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	09/13/2012

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