Provider Demographics
NPI:1952602674
Name:TIU, JOSE GORGONIA JR (DPT)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:GORGONIA
Last Name:TIU
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 S EASTERN AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6118
Mailing Address - Country:US
Mailing Address - Phone:702-673-3848
Mailing Address - Fax:
Practice Address - Street 1:4510 S EASTERN AVE STE 5
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6118
Practice Address - Country:US
Practice Address - Phone:702-673-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2022-01-19
Deactivation Date:2020-01-17
Deactivation Code:
Reactivation Date:2020-02-28
Provider Licenses
StateLicense IDTaxonomies
CA38093225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist