Provider Demographics
NPI:1922158484
Name:DER BOGHOSSIAN, PABLO EDGARDO (PT)
Entity Type:Individual
Prefix:MR
First Name:PABLO
Middle Name:EDGARDO
Last Name:DER BOGHOSSIAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 5887
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-5887
Mailing Address - Country:US
Mailing Address - Phone:941-870-7473
Mailing Address - Fax:941-870-4915
Practice Address - Street 1:1800 CORTEZ RD W STE C
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1335
Practice Address - Country:US
Practice Address - Phone:941-870-7473
Practice Address - Fax:941-870-4915
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
2251G0304X, 2251X0800X
PT134672251S0007X
FLPT0013467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7435YMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE