Provider Demographics
NPI:1972566438
Name:MULLES, DEXTER S (PT)
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:S
Last Name:MULLES
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 1:632 DEL PRADO BLVD N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2278
Mailing Address - Country:US
Mailing Address - Phone:239-772-5577
Mailing Address - Fax:239-772-9961
Practice Address - Street 1:632 DEL PRADO BLVD N
Practice Address - Street 2:SUITE 101
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2278
Practice Address - Country:US
Practice Address - Phone:239-772-5577
Practice Address - Fax:239-772-9961
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1290460001Medicare NSC
FLU7511ZMedicare PIN