Provider Demographics
NPI:1396205142
Name:SAMUEL, VISHAL (DPT)
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 N OCEAN DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE BY THE SEA
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2920
Mailing Address - Country:US
Mailing Address - Phone:954-545-4922
Mailing Address - Fax:
Practice Address - Street 1:4747 N OCEAN DR STE 261
Practice Address - Street 2:
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-2956
Practice Address - Country:US
Practice Address - Phone:954-545-4922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT34398OtherFLORIDA LICENSE