Provider Demographics
NPI:1962490938
Name:HISAMOTO, JOHN ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALLEN
Last Name:HISAMOTO
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 1:22819 SOUTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-4755
Mailing Address - Country:US
Mailing Address - Phone:813-979-4819
Mailing Address - Fax:813-975-8708
Practice Address - Street 1:13801 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3946
Practice Address - Country:US
Practice Address - Phone:813-979-4819
Practice Address - Fax:813-975-8708
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K2780OtherMEDICARE GROUP NUMBER
Y4306OtherBLUE CROSS BLUE SHIELD
Y4306OtherBLUE CROSS BLUE SHIELD
Y4306ZMedicare ID - Type Unspecified