Provider Demographics
NPI:1740052588
Name:DUCUSIN, IVAN (PT,DPT)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DUCUSIN
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 1:968 MCCAIN VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2834
Mailing Address - Country:US
Mailing Address - Phone:619-955-2518
Mailing Address - Fax:
Practice Address - Street 1:910 HALE PL STE 115
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3504
Practice Address - Country:US
Practice Address - Phone:619-369-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist