Provider Demographics
NPI:1699954453
Name:CUSTOR, FREDERICK A (MPT)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:A
Last Name:CUSTOR
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 BRAMBLE OAKS CT
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-3426
Mailing Address - Country:US
Mailing Address - Phone:817-354-5986
Mailing Address - Fax:
Practice Address - Street 1:3016 BRAMBLE OAKS CT
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-3426
Practice Address - Country:US
Practice Address - Phone:817-354-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1157290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist