1992283766 NPI number — MR. JUAN DANIEL MALDONADO JR. DPT

Table of content: MR. JUAN DANIEL MALDONADO JR. DPT (NPI 1992283766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992283766 NPI number — MR. JUAN DANIEL MALDONADO JR. DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALDONADO
Provider First Name:
JUAN
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992283766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4430 MISSOURI AVENUE
Provider Second Line Business Mailing Address:
BOX #1267
Provider Business Mailing Address City Name:
FORT LEONARD WOOD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-596-1707
Provider Business Mailing Address Fax Number:
321-802-5811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4430 MISSOURI AVENUE
Provider Second Line Business Practice Location Address:
BOX #1267
Provider Business Practice Location Address City Name:
FORT LEONARD WOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-596-0417
Provider Business Practice Location Address Fax Number:
321-802-5811
Provider Enumeration Date:
08/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT33776 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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