Provider Demographics
NPI:1093815532
Name:GUPTON, BRIAN WESLEY (DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WESLEY
Last Name:GUPTON
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:PO BOX 48116
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-8116
Mailing Address - Country:US
Mailing Address - Phone:904-725-1657
Mailing Address - Fax:904-725-7247
Practice Address - Street 1:880 A1A N
Practice Address - Street 2:STE 18A
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3220
Practice Address - Country:US
Practice Address - Phone:904-778-7501
Practice Address - Fax:904-778-7504
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0578OtherBCBS