Provider Demographics
NPI:1356333124
Name:DIMARCO, THOMAS GLENN (OT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:GLENN
Last Name:DIMARCO
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 N WICKHAM RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2369
Mailing Address - Country:US
Mailing Address - Phone:321-255-9546
Mailing Address - Fax:321-255-4690
Practice Address - Street 1:3040 N WICKHAM RD
Practice Address - Street 2:SUITE 7
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2369
Practice Address - Country:US
Practice Address - Phone:321-255-9546
Practice Address - Fax:321-255-4690
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 9438225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3479ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER