NPIMap

Organization Active NPI

Dynamic Physical Therapy of Jacksonville

  • Physical Therapist
  • Jacksonville, FL
National Provider Identifier
1770694788
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
PT10089 Issued in FL
Legal business name
DYNAMIC PHYSICAL THERAPY OF JACKSONVILLE
Practice address
1717 Blanding Blvd
Ste 104
Jacksonville, FL 32210
Phone
(904) 381-9205
Fax
(904) 381-9208
NPI assigned
Aug 31, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Onofre Fernan Miranda
Title
President
Phone
(904) 381-9207

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193400000X SINGLE SPECIALTY GROUP 225100000X PT10089 FL Primary

Addresses

Primary practice location

1717 Blanding Blvd
Ste 104
Jacksonville, FL 32210

Mailing address

1717 Blanding Blvd
Ste 104
Jacksonville, FL 32210
Phone (904) 381-9205

Other identifiers 1

IdentifierTypeStateIssuer
Y914MOtherFLBCBS

National Provider Directory

National Provider Directory

Locations

1717 Blanding Blvd
Ste 104
Jacksonville, FL 32210
Phone (904) 381-9205

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1770694788",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1717 BLANDING BLVD",
            "address_2": "STE 104",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "32210",
            "telephone_number": "904-381-9205",
            "fax_number": "904-381-9208"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1717 BLANDING BLVD",
            "address_2": "STE 104",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "32210",
            "telephone_number": "904-381-9205",
            "fax_number": "904-381-9208"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DYNAMIC PHYSICAL THERAPY OF JACKSONVILLE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-31",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "MIRANDA",
        "authorized_official_first_name": "ONOFRE",
        "authorized_official_middle_name": "FERNAN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "904-381-9207",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Therapist",
            "state": "FL",
            "license": "PT10089",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "Y914M",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.