Provider Demographics
NPI:1174891964
Name:FIELDS, GORDON R (DPT, CSCS)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:R
Last Name:FIELDS
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34990 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-1920
Mailing Address - Country:US
Mailing Address - Phone:727-210-0760
Mailing Address - Fax:727-210-0671
Practice Address - Street 1:34990 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1920
Practice Address - Country:US
Practice Address - Phone:727-210-0760
Practice Address - Fax:727-210-0671
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist