Provider Demographics
NPI:1982761003
Name:JOVELLANOS, CESAREO TAMAYO (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:CESAREO
Middle Name:TAMAYO
Last Name:JOVELLANOS
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7633 EAST JEFFERSON
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214
Mailing Address - Country:US
Mailing Address - Phone:313-499-4309
Mailing Address - Fax:
Practice Address - Street 1:7633 EAST JEFFERSON
Practice Address - Street 2:SUITE 170
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214
Practice Address - Country:US
Practice Address - Phone:313-499-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist