Provider Demographics
NPI:1700955887
Name:AVERGONZADO, ARTURO JR (RPT)
Entity type:Individual
Prefix:MS
First Name:ARTURO
Middle Name:
Last Name:AVERGONZADO
Suffix:JR
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3039 CONGRESS DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8030
Mailing Address - Country:US
Mailing Address - Phone:765-513-9287
Mailing Address - Fax:765-455-2824
Practice Address - Street 1:3039 CONGRESS DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-8030
Practice Address - Country:US
Practice Address - Phone:765-513-9287
Practice Address - Fax:765-455-2824
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007798A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics