Provider Demographics
NPI:1669952123
Name:REUPERT, FRED PAUL
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:PAUL
Last Name:REUPERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-3300
Mailing Address - Country:US
Mailing Address - Phone:979-541-9825
Mailing Address - Fax:
Practice Address - Street 1:1220 SUNNY LN
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-3300
Practice Address - Country:US
Practice Address - Phone:979-532-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2027837225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant