Provider Demographics
NPI:1902533169
Name:PIETROBURGO, JESSE MCCOY (DPT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:MCCOY
Last Name:PIETROBURGO
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 1:105 E VILLA CAPRI CIR APT D
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7859
Mailing Address - Country:US
Mailing Address - Phone:573-529-5084
Mailing Address - Fax:
Practice Address - Street 1:739A S NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7332
Practice Address - Country:US
Practice Address - Phone:386-671-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT39083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist