Provider Demographics
NPI:1306036363
Name:HOLTHAUS, RONALD (PT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:HOLTHAUS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:RONALD
Other - Middle Name:
Other - Last Name:HOLTHAUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1950 BLUEWATER BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3887
Mailing Address - Country:US
Mailing Address - Phone:850-897-3334
Mailing Address - Fax:850-897-7855
Practice Address - Street 1:1950 BLUEWATER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3887
Practice Address - Country:US
Practice Address - Phone:850-897-3334
Practice Address - Fax:850-897-7855
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIN504ZOtherMEDICARE PTAN