Provider Demographics
NPI:1255465993
Name:DAVIS, MANDI (PT)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:
Other - Last Name:BUCKHEIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4141 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 18
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-3600
Mailing Address - Country:US
Mailing Address - Phone:941-924-3022
Mailing Address - Fax:941-925-4943
Practice Address - Street 1:4141 S TAMIAMI TRL
Practice Address - Street 2:SUITE 18
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-3600
Practice Address - Country:US
Practice Address - Phone:941-924-3022
Practice Address - Fax:941-925-4943
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY053FZMedicare ID - Type UnspecifiedMEDICARE