Provider Demographics
NPI:1144987686
Name:BAJALA, IVAN QUIBETE (PT, DPT)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:QUIBETE
Last Name:BAJALA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11523 OXCROFT CT
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-4666
Mailing Address - Country:US
Mailing Address - Phone:727-457-5969
Mailing Address - Fax:
Practice Address - Street 1:11523 OXCROFT CT
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-4666
Practice Address - Country:US
Practice Address - Phone:727-457-5969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist