Provider Demographics
NPI:1407866437
Name:MCCORKLE, DOUGLAS R (PT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:R
Last Name:MCCORKLE
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 1:247 CANOE BROOK RD
Mailing Address - Street 2:
Mailing Address - City:E DUMMERSTON
Mailing Address - State:VT
Mailing Address - Zip Code:05346-9770
Mailing Address - Country:US
Mailing Address - Phone:802-387-3025
Mailing Address - Fax:802-387-3025
Practice Address - Street 1:247 CANOE BROOK RD
Practice Address - Street 2:
Practice Address - City:E DUMMERSTON
Practice Address - State:VT
Practice Address - Zip Code:05346-9770
Practice Address - Country:US
Practice Address - Phone:802-387-3025
Practice Address - Fax:802-387-3025
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2014-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT49955OtherBCBS
11325931OtherCAQH
VTVN252202OtherMEDICARE PTAN
VT0VN2522Medicaid
E16585Medicare UPIN