Provider Demographics
NPI:1205928710
Name:CORDOVA, GASTON D (PT)
Entity type:Individual
Prefix:
First Name:GASTON
Middle Name:D
Last Name:CORDOVA
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 1:121 SANTA FE LN
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4390 IL-71
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543
Practice Address - Country:US
Practice Address - Phone:630-554-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26744Medicare ID - Type UnspecifiedMEDICARE MEMBER NUMBER