Provider Demographics
NPI:1811687478
Name:CORNEJO, RANDY SALVADOR (PT, DPT)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:SALVADOR
Last Name:CORNEJO
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 1:7956 KLAMATH MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-4359
Mailing Address - Country:US
Mailing Address - Phone:713-818-5924
Mailing Address - Fax:
Practice Address - Street 1:5690 BOLLETTIERI BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-2211
Practice Address - Country:US
Practice Address - Phone:941-739-7540
Practice Address - Fax:941-752-2626
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1375925225100000X
FLME41236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist