Provider Demographics
NPI:1619133840
Name:STAJDUHAR, MARTY (PHYSICAL THERAPY)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:
Last Name:STAJDUHAR
Suffix:
Gender:M
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 MARTIN DR STE B
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-3839
Mailing Address - Country:US
Mailing Address - Phone:817-545-9793
Mailing Address - Fax:817-581-9221
Practice Address - Street 1:2901 MARTIN DR STE B
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-3839
Practice Address - Country:US
Practice Address - Phone:817-545-9793
Practice Address - Fax:817-581-9221
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1047785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83194TOtherBCBS PROVIDER #