Provider Demographics
NPI:1386640902
Name:KORCEK, DOUGLAS SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:SCOTT
Last Name:KORCEK
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:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:FORT JONES
Mailing Address - State:CA
Mailing Address - Zip Code:96032-0217
Mailing Address - Country:US
Mailing Address - Phone:530-468-5528
Mailing Address - Fax:530-468-5445
Practice Address - Street 1:122 SCOTT RIVER RD
Practice Address - Street 2:
Practice Address - City:FORT JONES
Practice Address - State:CA
Practice Address - Zip Code:96032-9620
Practice Address - Country:US
Practice Address - Phone:530-468-5528
Practice Address - Fax:530-468-5445
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2008-05-06
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
CAPT9569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0095690Medicaid
CAPT0095690Medicaid
CAP00464117Medicare PIN
CA00PT95692Medicare PIN
CA0780890001Medicare NSC