Provider Demographics
NPI:1295253060
Name:SHODA, BARTHOLOMEW J (PTA)
Entity type:Individual
Prefix:
First Name:BARTHOLOMEW
Middle Name:J
Last Name:SHODA
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 1:169 BUCKEYE AVE NW
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9064
Mailing Address - Country:US
Mailing Address - Phone:941-457-2133
Mailing Address - Fax:
Practice Address - Street 1:216 SANTA BARBARA BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2031
Practice Address - Country:US
Practice Address - Phone:239-573-9693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27763225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant