Provider Demographics
NPI:1346257805
Name:SOUTULLO, FERNANDO (PT)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:SOUTULLO
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 1:8224 HARDING AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-5213
Mailing Address - Country:US
Mailing Address - Phone:786-306-0778
Mailing Address - Fax:
Practice Address - Street 1:600 NW 35TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4000
Practice Address - Country:US
Practice Address - Phone:866-699-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41255225100000X
FL19318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist