Provider Demographics
NPI:1497107858
Name:WORSOWICZ, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:WORSOWICZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SAN MARCO BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8566
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6489
Practice Address - Street 1:1325 SAN MARCO BLVD STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8549
Practice Address - Country:US
Practice Address - Phone:904-858-7045
Practice Address - Fax:904-858-7047
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist