Provider Demographics
NPI:1659026417
Name:RODGERS, EZRA (PT)
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PAYNE ST LOT 8
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-3891
Mailing Address - Country:US
Mailing Address - Phone:850-346-1547
Mailing Address - Fax:
Practice Address - Street 1:11 PAYNE ST LOT 8
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-3891
Practice Address - Country:US
Practice Address - Phone:850-346-1547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT33351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist