Provider Demographics
NPI:1982278057
Name:GERSTEIN, MICHAEL PHILLIP
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:GERSTEIN
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 1:251 PARK BLVD APT 211
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-0553
Mailing Address - Country:US
Mailing Address - Phone:248-875-5036
Mailing Address - Fax:
Practice Address - Street 1:1205 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-8300
Practice Address - Country:US
Practice Address - Phone:801-876-5980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12104034-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12104034-2402OtherPTA LICENSE NUMBER