Provider Demographics
NPI:1114610904
Name:ISIDRO, MARIA ROSARIO CHARLE MENDOZA (PT)
Entity Type:Individual
Prefix:
First Name:MARIA ROSARIO CHARLE
Middle Name:MENDOZA
Last Name:ISIDRO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 SAWGRASS CORPORATE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2869
Mailing Address - Country:US
Mailing Address - Phone:954-739-4247
Mailing Address - Fax:
Practice Address - Street 1:2221 AVENUE J
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-5867
Practice Address - Country:US
Practice Address - Phone:817-633-3152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1286877208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty