Provider Demographics
NPI:1750746798
Name:FOX, MARY (PT, DPT, OCS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FOX
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:GINNY
Other - Middle Name:
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3903 NORTHDALE BLVD
Mailing Address - Street 2:STE 111W
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1853
Mailing Address - Country:US
Mailing Address - Phone:727-475-5543
Mailing Address - Fax:
Practice Address - Street 1:612 DRUID RD E
Practice Address - Street 2:STE D
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3912
Practice Address - Country:US
Practice Address - Phone:727-475-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL309802251X0800X
FLPT30980225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016402200Medicaid
FLRWEG2OtherBLUE CROSS BLUE SHIELD
FL016402200Medicaid