Provider Demographics
NPI:1740428226
Name:MASSENBURG, MICHAEL G (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:MASSENBURG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670769
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75367-0769
Mailing Address - Country:US
Mailing Address - Phone:214-239-0990
Mailing Address - Fax:214-239-0991
Practice Address - Street 1:7115 GREENVILLE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5100
Practice Address - Country:US
Practice Address - Phone:214-239-0990
Practice Address - Fax:214-239-0991
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1186858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX812T75OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX8L8341Medicare PIN