Provider Demographics
NPI:1194381616
Name:MEDELEZ, BEN III (PTA)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:MEDELEZ
Suffix:III
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 N. EXPRESSWAY 77, STE C
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526
Mailing Address - Country:US
Mailing Address - Phone:956-350-6696
Mailing Address - Fax:956-350-6604
Practice Address - Street 1:4920 N. EXPRESSWAY 77, STE C
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526
Practice Address - Country:US
Practice Address - Phone:956-350-6696
Practice Address - Fax:956-350-6604
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2056760225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant