Provider Demographics
NPI:1285857904
Name:LANDGRAF, TED RYAN (DPT)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:RYAN
Last Name:LANDGRAF
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1938
Mailing Address - Country:US
Mailing Address - Phone:321-725-2225
Mailing Address - Fax:321-308-0635
Practice Address - Street 1:709 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1938
Practice Address - Country:US
Practice Address - Phone:321-725-2225
Practice Address - Fax:321-308-0635
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY121QOtherBCBS OF FLORIDA
FL892788000Medicaid
FLAI682WMedicare PIN