Provider Demographics
NPI:1174567481
Name:SAUSA, DIEGO DIAZ JR (MA, DPT)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:DIAZ
Last Name:SAUSA
Suffix:JR
Gender:M
Credentials:MA, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2565
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2565
Mailing Address - Country:US
Mailing Address - Phone:239-850-1891
Mailing Address - Fax:239-561-1310
Practice Address - Street 1:14630 PALM BEACH BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2333
Practice Address - Country:US
Practice Address - Phone:239-690-3100
Practice Address - Fax:239-693-3200
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 7037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP66047Medicare UPIN
FLE7933Medicare ID - Type UnspecifiedPART B PROVIDER NUMBER