Provider Demographics
NPI:1962674564
Name:VANDAL, JEROME (PT)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:VANDAL
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 1:6000 TURKEY LAKE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4200
Mailing Address - Country:US
Mailing Address - Phone:407-352-3508
Mailing Address - Fax:407-352-1219
Practice Address - Street 1:6000 TURKEY LAKE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-4200
Practice Address - Country:US
Practice Address - Phone:407-352-3508
Practice Address - Fax:407-352-1219
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT176722251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic