Provider Demographics
NPI:1124591896
Name:DEFEO, DYLAN (DPT)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:DEFEO
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 1:345 W MICHIGAN ST STE 108
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4465
Mailing Address - Country:US
Mailing Address - Phone:407-888-2255
Mailing Address - Fax:
Practice Address - Street 1:345 W MICHIGAN ST STE 108
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4465
Practice Address - Country:US
Practice Address - Phone:407-888-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-06
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1548217615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121212Medicaid