Provider Demographics
NPI:1902142862
Name:PERDOMO, CARLOS RAULO (PTA)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:RAULO
Last Name:PERDOMO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 YUMURI ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-3607
Mailing Address - Country:US
Mailing Address - Phone:305-414-4967
Mailing Address - Fax:
Practice Address - Street 1:955 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-1274
Practice Address - Country:US
Practice Address - Phone:305-548-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20525225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant