Provider Demographics
NPI:1164854311
Name:MADRID, ISIDRO TUCKER JR
Entity Type:Individual
Prefix:
First Name:ISIDRO
Middle Name:TUCKER
Last Name:MADRID
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 S 10TH ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5602
Mailing Address - Country:US
Mailing Address - Phone:863-421-2000
Mailing Address - Fax:863-421-2002
Practice Address - Street 1:306 S 10TH ST
Practice Address - Street 2:SUITE 310
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5602
Practice Address - Country:US
Practice Address - Phone:863-421-2000
Practice Address - Fax:863-421-2002
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTAT24311225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant