Provider Demographics
NPI:1205981628
Name:CERVANTEZ, ROBERT D (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:CERVANTEZ
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:PO BOX 682226
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068
Mailing Address - Country:US
Mailing Address - Phone:435-645-9095
Mailing Address - Fax:435-645-9092
Practice Address - Street 1:2015 SIDEWINDER DR.
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
Practice Address - Country:US
Practice Address - Phone:435-645-9095
Practice Address - Fax:435-645-9092
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT849822401225100000X
UT284982-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT280669988016Medicaid
UT005567003Medicare UPIN