Provider Demographics
NPI:1861733305
Name:ENTROLEZO, MARK ANTHONY ANAHAW (PT)
Entity type:Individual
Prefix:MR
First Name:MARK ANTHONY
Middle Name:ANAHAW
Last Name:ENTROLEZO
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 1:220 SAN LORENZO ST
Mailing Address - Street 2:BRGY SAN GABRIEL
Mailing Address - City:GMA
Mailing Address - State:CAVITE
Mailing Address - Zip Code:4117
Mailing Address - Country:PH
Mailing Address - Phone:046-542-1389
Mailing Address - Fax:
Practice Address - Street 1:3404 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3136
Practice Address - Country:US
Practice Address - Phone:903-304-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1217131225100000X
FLPT 27283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist