Provider Demographics
NPI:1679041081
Name:ELIZONDO, MAURICIO (PT, DPT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:ELIZONDO
Suffix:
Gender:M
Credentials:PT, DPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16627 FISHHAWK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-3800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 ATP TOUR BLVD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3211
Practice Address - Country:US
Practice Address - Phone:480-208-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT333272251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports