Provider Demographics
NPI:1659433944
Name:GAUDRY, JOHN (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GAUDRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 LAURA LN
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1914
Mailing Address - Country:US
Mailing Address - Phone:440-960-0444
Mailing Address - Fax:
Practice Address - Street 1:1317 COOPER FOSTER PARK RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1201
Practice Address - Country:US
Practice Address - Phone:440-282-3341
Practice Address - Fax:440-282-9153
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT02036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2412606Medicaid
OH2412606Medicaid
OHR72483Medicare UPIN