Provider Demographics
NPI:1740056324
Name:DORANTES, RODOLFO TOM
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:TOM
Last Name:DORANTES
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 1:427 HARRIS PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6701
Mailing Address - Country:US
Mailing Address - Phone:502-649-3504
Mailing Address - Fax:
Practice Address - Street 1:10301 CONEFLOWER LN
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8355
Practice Address - Country:US
Practice Address - Phone:502-290-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPTA02228225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant