Provider Demographics
NPI:1437332764
Name:OLDHAM, JONATHAN (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:OLDHAM
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 1:2955 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2356
Mailing Address - Country:US
Mailing Address - Phone:303-444-8707
Mailing Address - Fax:303-444-8109
Practice Address - Street 1:2955 BASELINE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2356
Practice Address - Country:US
Practice Address - Phone:303-444-8707
Practice Address - Fax:303-444-8109
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6917174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist