Provider Demographics
NPI:1679681191
Name:ANDERSON, BRENT D (PHD,PT,OCS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHD,PT,OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9390 SW 106 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176
Mailing Address - Country:US
Mailing Address - Phone:305-740-6001
Mailing Address - Fax:305-740-6998
Practice Address - Street 1:1500 MONZA SUITE 350
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-3005
Practice Address - Country:US
Practice Address - Phone:305-740-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 15749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4090ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER