Provider Demographics
NPI:1104436989
Name:O'GARA, DERRICK J (PTA)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:J
Last Name:O'GARA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32655 TAYLOR GRADE RD
Mailing Address - Street 2:
Mailing Address - City:DUETTE
Mailing Address - State:FL
Mailing Address - Zip Code:34219-7916
Mailing Address - Country:US
Mailing Address - Phone:712-209-5015
Mailing Address - Fax:
Practice Address - Street 1:32655 TAYLOR GRADE RD
Practice Address - Street 2:
Practice Address - City:DUETTE
Practice Address - State:FL
Practice Address - Zip Code:34219-7916
Practice Address - Country:US
Practice Address - Phone:712-209-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty