Provider Demographics
NPI:1104907591
Name:ESPARZA, TED J (PT)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:J
Last Name:ESPARZA
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 1:3870 MASTHEAD ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4479
Mailing Address - Country:US
Mailing Address - Phone:505-830-3678
Mailing Address - Fax:505-830-6505
Practice Address - Street 1:3870 MASTHEAD ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4479
Practice Address - Country:US
Practice Address - Phone:505-830-3678
Practice Address - Fax:505-830-6505
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2523225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM38706539Medicaid
NM38706539Medicaid