Provider Demographics
NPI:1467690206
Name:DOUGLAS, JOHN F (PTA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HAMILTON PL
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1915
Mailing Address - Country:US
Mailing Address - Phone:516-454-6387
Mailing Address - Fax:516-454-6387
Practice Address - Street 1:1061 N BROADWAY
Practice Address - Street 2:
Practice Address - City:N MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1853
Practice Address - Country:US
Practice Address - Phone:516-454-6387
Practice Address - Fax:516-454-6387
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003072-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant