Provider Demographics
NPI:1275533739
Name:STODDARD, PHILIP LESLIE (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:LESLIE
Last Name:STODDARD
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 1:295 GRASS VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-4533
Mailing Address - Country:US
Mailing Address - Phone:530-888-8326
Mailing Address - Fax:530-888-1920
Practice Address - Street 1:295 GRASS VALLEY HWY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-4533
Practice Address - Country:US
Practice Address - Phone:530-888-8326
Practice Address - Fax:530-888-1920
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
13067OtherNONE
155990Medicare ID - Type Unspecified