Provider Demographics
NPI: | 1467581603 |
---|---|
Name: | OCAMPO, REYMON DAVID (PT) |
Entity Type: | Individual |
Prefix: | |
First Name: | REYMON |
Middle Name: | DAVID |
Last Name: | OCAMPO |
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: | 905 HAMILTON PLACE DR |
Mailing Address - Street 2: | |
Mailing Address - City: | LAKELAND |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33813-2668 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 863-286-1836 |
Mailing Address - Fax: | 888-847-0781 |
Practice Address - Street 1: | 905 HAMILTON PLACE DR |
Practice Address - Street 2: | |
Practice Address - City: | LAKELAND |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33813-2668 |
Practice Address - Country: | US |
Practice Address - Phone: | 863-286-1836 |
Practice Address - Fax: | 863-286-1836 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-03-05 |
Last Update Date: | 2016-01-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PT16026 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | Y910G | Other | BCBS GROUP NO. |
FL | E6970Z | Medicare ID - Type Unspecified | INDIVIDUAL NO. |
FL | K0936 | Medicare ID - Type Unspecified | GROUP NO. |