Provider Demographics
NPI:1619439551
Name:SODEMAN, GREGORY GORDON
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:GORDON
Last Name:SODEMAN
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 1:29858 SW 159TH DR
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3307
Mailing Address - Country:US
Mailing Address - Phone:305-505-5333
Mailing Address - Fax:
Practice Address - Street 1:311 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4738
Practice Address - Country:US
Practice Address - Phone:305-248-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20367225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty