Provider Demographics
NPI:1578752549
Name:MEDOSKY, GUSTAVO J (LMT)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:J
Last Name:MEDOSKY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6681 SW 20TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-5104
Mailing Address - Country:US
Mailing Address - Phone:954-536-0767
Mailing Address - Fax:
Practice Address - Street 1:205 SW 84TH AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2708
Practice Address - Country:US
Practice Address - Phone:954-536-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA19949225700000X
FLPTA27822225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist