Provider Demographics
NPI:1285944561
Name:FORMILLEZA, MODESTO KING ANDREW ESGUERRA V (OTR)
Entity type:Individual
Prefix:MR
First Name:MODESTO KING ANDREW
Middle Name:ESGUERRA
Last Name:FORMILLEZA
Suffix:V
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 POTTER ST APT 47
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-4583
Mailing Address - Country:US
Mailing Address - Phone:541-912-5595
Mailing Address - Fax:
Practice Address - Street 1:735 S 2ND ST
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-7507
Practice Address - Country:US
Practice Address - Phone:541-895-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR260743225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation