Provider Demographics
NPI:1063598761
Name:CORDOVA, PHILIP (PT)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:CORDOVA
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 1:1809 EAST DYER RD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:949-863-0022
Mailing Address - Fax:949-863-0023
Practice Address - Street 1:11633 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-263-1632
Practice Address - Fax:310-263-1652
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT28829AOtherPPIN
PT28829Medicare ID - Type Unspecified