Provider Demographics
NPI:1184817470
Name:VENZON, SANDRA (PT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:VENZON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6722 MEWALL DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-2114
Mailing Address - Country:US
Mailing Address - Phone:619-208-1709
Mailing Address - Fax:619-697-7939
Practice Address - Street 1:6722 MEWALL DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-2114
Practice Address - Country:US
Practice Address - Phone:619-208-1709
Practice Address - Fax:619-697-7939
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT5120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0051200Medicaid
CAWPT5120AMedicare PIN