1265580773 NPI number — MR. DOUGLAS MERRILL WISOFF PHYSICAL THERAPIST

Table of content: MR. DOUGLAS MERRILL WISOFF PHYSICAL THERAPIST (NPI 1265580773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265580773 NPI number — MR. DOUGLAS MERRILL WISOFF PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISOFF
Provider First Name:
DOUGLAS
Provider Middle Name:
MERRILL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WISOFF
Provider Other First Name:
DOUGLAS
Provider Other Middle Name:
MERRILL
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1265580773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3602
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80307-3602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-499-2062
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1295 S BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80305-6768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-499-2062
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

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:  3112 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3112 . This is a "PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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