Provider Demographics
NPI:1134657224
Name:KALIVODA, JASON RICHARD (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:RICHARD
Last Name:KALIVODA
Suffix:
Gender:M
Credentials:PT, DPT
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 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:252-726-1802
Mailing Address - Fax:252-726-1805
Practice Address - Street 1:105 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:NC
Practice Address - Zip Code:28516-2418
Practice Address - Country:US
Practice Address - Phone:252-726-1802
Practice Address - Fax:252-726-1805
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP16995OtherPT LICENSE