Provider Demographics
NPI:1093441271
Name:WONGSOPAWIRO, DIMAS (PTA)
Entity Type:Individual
Prefix:
First Name:DIMAS
Middle Name:
Last Name:WONGSOPAWIRO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 NE 162ND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4357
Mailing Address - Country:US
Mailing Address - Phone:305-450-4557
Mailing Address - Fax:
Practice Address - Street 1:540 NE 162ND ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4357
Practice Address - Country:US
Practice Address - Phone:305-450-4557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31097225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant