Provider Demographics
NPI:1306962493
Name:GHOUBRIAL, MARK B (DPT)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:GHOUBRIAL
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 1:218 AVONDALE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-3972
Mailing Address - Country:US
Mailing Address - Phone:126-726-3224
Mailing Address - Fax:
Practice Address - Street 1:2700 CLEMENS RD
Practice Address - Street 2:
Practice Address - City:HATFIELD
Practice Address - State:PA
Practice Address - Zip Code:19440-4202
Practice Address - Country:US
Practice Address - Phone:215-368-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT017467OtherLIC #