Provider Demographics
NPI:1164716312
Name:VANOOTEGHEM, TRENTON DONALD (DPT)
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:DONALD
Last Name:VANOOTEGHEM
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 1:4600 W BAY TO BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7601
Mailing Address - Country:US
Mailing Address - Phone:813-892-0912
Mailing Address - Fax:
Practice Address - Street 1:4600 W BAY TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-7601
Practice Address - Country:US
Practice Address - Phone:813-892-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist