Provider Demographics
NPI:1578166047
Name:BUDVARSON, COLE (DPT)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:BUDVARSON
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 1:4867 COLE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-3613
Mailing Address - Country:US
Mailing Address - Phone:619-402-9195
Mailing Address - Fax:
Practice Address - Street 1:1106 ALSTON AVE STE 120
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4622
Practice Address - Country:US
Practice Address - Phone:817-332-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1339905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist