Provider Demographics
NPI:1972709905
Name:MORTILLARO, ROBERT J (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:MORTILLARO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 HEARTHSTONE CT
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-2531
Mailing Address - Country:US
Mailing Address - Phone:727-938-8384
Mailing Address - Fax:
Practice Address - Street 1:33100 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3127
Practice Address - Country:US
Practice Address - Phone:727-789-6008
Practice Address - Fax:727-789-0716
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA9421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant