Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT26110 | CA |
N | 2251S0007X | Physical Therapist - Sports | PT26110 | CA |
N | 2251X0800X | Physical Therapist - Orthopedic | PT26110 | CA |
NPI | 1528163136 |
---|---|
Provider Name | John Logan Fox |
First Address | Murrieta, CA 92562-6131 |
Second Address | S Pasadena, CA 91030-2906 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2006 |
Last Update Date | 10/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0PT261100 | BLUE SHIELD OF CALIFORNIA (01) | CA |