Provider Demographics
NPI:1023223443
Name:DE JESUS, WALTER TABLANTE (RPT)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:TABLANTE
Last Name:DE JESUS
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13578 HATCHER PL
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-2945
Mailing Address - Country:US
Mailing Address - Phone:909-641-1096
Mailing Address - Fax:
Practice Address - Street 1:13578 HATCHER PL
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-2945
Practice Address - Country:US
Practice Address - Phone:909-641-1096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist