Provider Demographics
NPI:1225081169
Name:GOTARDO, PHILIP GUY (PT)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:GUY
Last Name:GOTARDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:713-830-3033
Mailing Address - Fax:713-523-4897
Practice Address - Street 1:3311 RICHMOND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098
Practice Address - Country:US
Practice Address - Phone:713-830-3033
Practice Address - Fax:713-523-4897
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1111961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180641601Medicaid
TX180641602Medicaid
TXB21342Medicare UPIN
TX8J3132Medicare PIN
TX8592B1Medicare ID - Type Unspecified