Provider Demographics
NPI:1306115621
Name:TADROS, SAMY S (PT)
Entity type:Individual
Prefix:
First Name:SAMY
Middle Name:S
Last Name:TADROS
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 1:1075 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4690
Mailing Address - Country:US
Mailing Address - Phone:386-255-4596
Mailing Address - Fax:386-257-0558
Practice Address - Street 1:1075 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4690
Practice Address - Country:US
Practice Address - Phone:386-255-4596
Practice Address - Fax:386-257-0558
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209874225100000X
NY031785225100000X
FLPT308152251X0800X
FL30815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019347000Medicaid