Provider Demographics
NPI:1265702807
Name:MEDIATE, CHAD DAVID (DPT)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:DAVID
Last Name:MEDIATE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 1/2 ARNOLD AVE
Mailing Address - Street 2:1/2
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3441
Mailing Address - Country:US
Mailing Address - Phone:216-272-0558
Mailing Address - Fax:
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR
Practice Address - Street 2:SUITE 306
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9121
Practice Address - Country:US
Practice Address - Phone:858-455-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37003225100000X
OH012196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist