Provider Demographics
NPI:1063461101
Name:BOUTELLE, DAVID C (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:C
Last Name:BOUTELLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2310
Mailing Address - Country:US
Mailing Address - Phone:760-591-7750
Mailing Address - Fax:760-294-9813
Practice Address - Street 1:3070 MADISON ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2310
Practice Address - Country:US
Practice Address - Phone:760-591-7750
Practice Address - Fax:760-471-5139
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12422225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT12422HMedicare PIN
CAWPT12422JMedicare PIN
CAWPT12422DMedicare PIN
CAWPT12422EMedicare PIN
CAWPT12422IMedicare PIN
CAWPT12422FMedicare PIN