Provider Demographics
NPI:1073222659
Name:STODDARD, AUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:STODDARD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 BENNETT AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-4906
Mailing Address - Country:US
Mailing Address - Phone:208-678-1191
Mailing Address - Fax:
Practice Address - Street 1:1263 BENNETT AVE STE 2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-4906
Practice Address - Country:US
Practice Address - Phone:208-678-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-8373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1669530051Medicaid