Provider Demographics
NPI:1043315765
Name:SOUZA, GARY M (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:SOUZA
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21015 PATHFINDER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4002
Mailing Address - Country:US
Mailing Address - Phone:909-861-3511
Mailing Address - Fax:909-860-7900
Practice Address - Street 1:1370 VALLEY VISTA DR STE 145
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3950
Practice Address - Country:US
Practice Address - Phone:909-861-3511
Practice Address - Fax:909-860-7900
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT10462AMedicare ID - Type UnspecifiedMEDICARE PROVIDER #