Provider Demographics
NPI:1063555969
Name:MAHALARIS, BRIAN JOHN (PT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOHN
Last Name:MAHALARIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11701 SAN JOSE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-0756
Mailing Address - Country:US
Mailing Address - Phone:904-858-7450
Mailing Address - Fax:904-858-7451
Practice Address - Street 1:11701 SAN JOSE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-0756
Practice Address - Country:US
Practice Address - Phone:904-858-7450
Practice Address - Fax:904-858-7451
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 20758225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889766200Medicaid