Provider Demographics
NPI:1518713676
Name:AVERY, ROBERT CHARLES (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHARLES
Last Name:AVERY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 EDSALL LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2870
Mailing Address - Country:US
Mailing Address - Phone:716-474-1226
Mailing Address - Fax:
Practice Address - Street 1:120 C AVE STE 110
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1992
Practice Address - Country:US
Practice Address - Phone:858-225-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT305488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist