Provider Demographics
NPI:1689708026
Name:DEROUAUX, MARK (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DEROUAUX
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 1:1 TOMOKA OAKS BLVD
Mailing Address - Street 2:#134
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3801
Mailing Address - Country:US
Mailing Address - Phone:386-673-1809
Mailing Address - Fax:386-673-3998
Practice Address - Street 1:535 N NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4405
Practice Address - Country:US
Practice Address - Phone:386-673-1809
Practice Address - Fax:386-673-3998
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist