Provider Demographics
NPI:1326262841
Name:MITRY, ATEF FARAH (PHYSICAL THERAPY)
Entity Type:Individual
Prefix:
First Name:ATEF
Middle Name:FARAH
Last Name:MITRY
Suffix:
Gender:M
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 S NOVA RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127
Mailing Address - Country:US
Mailing Address - Phone:386-767-0557
Mailing Address - Fax:386-757-3251
Practice Address - Street 1:3959 S NOVA R
Practice Address - Street 2:SUITE #1
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127
Practice Address - Country:US
Practice Address - Phone:386-767-0557
Practice Address - Fax:386-757-3251
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7670Medicare ID - Type Unspecified