Provider Demographics
NPI:1639190044
Name:PHILLIPS, ANTHONY MICHAEL (DPT)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:PHILLIPS
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 1:413 GOLDEN LEAF CT
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-1110
Mailing Address - Country:US
Mailing Address - Phone:209-835-4888
Mailing Address - Fax:209-835-6424
Practice Address - Street 1:1450 BESSIE AVENUE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376
Practice Address - Country:US
Practice Address - Phone:209-835-4888
Practice Address - Fax:209-835-6424
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007OtherUNITED HEALTH CARE
CA098313OtherHEALTH NET
CA65730OtherINTERPLAN
CAGR0087960Medicaid
CAPT00026664OtherBLUE CROSS
CAZZZ09778ZOtherBLUE SHIELD
CAGR0087960Medicaid