Provider Demographics
NPI:1124039243
Name:KAZALAS, JOHN CHRISTOPHER (MPT,)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:KAZALAS
Suffix:
Gender:M
Credentials:MPT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-0844
Mailing Address - Country:US
Mailing Address - Phone:412-779-1164
Mailing Address - Fax:
Practice Address - Street 1:54 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3508
Practice Address - Country:US
Practice Address - Phone:304-235-4300
Practice Address - Fax:304-235-0176
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002017225100000X
PAPT013202L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV571136141002OtherBC/BS
WV3810000543Medicaid
WV3810000543Medicaid