Provider Demographics
NPI:1578706057
Name:DECASTRO, MIGUEL TRAIFALGAR JR (PT)
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:TRAIFALGAR
Last Name:DECASTRO
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6722 71ST ST E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-7173
Mailing Address - Country:US
Mailing Address - Phone:941-758-1283
Mailing Address - Fax:
Practice Address - Street 1:4730 BEE RIDGE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1442
Practice Address - Country:US
Practice Address - Phone:941-377-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT-205852251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics