Provider Demographics
NPI:1093239386
Name:MOORE, CAMERON OLIN (DPT)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:OLIN
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8226 SANGUINELLI RD
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34637-7528
Mailing Address - Country:US
Mailing Address - Phone:620-440-1093
Mailing Address - Fax:
Practice Address - Street 1:3820 NORTHDALE BLVD STE 101A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1834
Practice Address - Country:US
Practice Address - Phone:813-264-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist