Provider Demographics
NPI:1649257767
Name:CORDOVA, ANTONIO III (MS, ATC)
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
Last Name:CORDOVA
Suffix:III
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 MORNING MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-7602
Mailing Address - Country:US
Mailing Address - Phone:904-386-0480
Mailing Address - Fax:
Practice Address - Street 1:4001 26TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-1930
Practice Address - Country:US
Practice Address - Phone:772-569-4900
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL14992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer