Provider Demographics
NPI:1982102877
Name:ISAAC, ONDREY TOBIAS
Entity type:Individual
Prefix:
First Name:ONDREY
Middle Name:TOBIAS
Last Name:ISAAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 AVENUE N
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-2055
Mailing Address - Country:US
Mailing Address - Phone:772-828-6370
Mailing Address - Fax:
Practice Address - Street 1:971 N HAIRSTON RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2871
Practice Address - Country:US
Practice Address - Phone:772-828-6370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL1259854335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier