Provider Demographics
NPI:1538282454
Name:INTRAVAIA, DOMINIC JOSEPH (DPT)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:JOSEPH
Last Name:INTRAVAIA
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 1:5796 147TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-2620
Mailing Address - Country:US
Mailing Address - Phone:727-724-4451
Mailing Address - Fax:
Practice Address - Street 1:31964 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3730
Practice Address - Country:US
Practice Address - Phone:727-786-2503
Practice Address - Fax:727-786-7949
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028158225100000X
FL27337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist