Provider Demographics
NPI:1205819513
Name:BOSTDORF, TREVOR (MPT/MTC)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:BOSTDORF
Suffix:
Gender:M
Credentials:MPT/MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14901 NATIONAL AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2637
Mailing Address - Country:US
Mailing Address - Phone:408-358-3631
Mailing Address - Fax:408-358-4537
Practice Address - Street 1:14901 NATIONAL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2637
Practice Address - Country:US
Practice Address - Phone:408-358-3631
Practice Address - Fax:408-358-4537
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABQ846ZMedicare UPIN