Provider Demographics
NPI:1508960980
Name:KOLANDER, JOHN DOUGLAS (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DOUGLAS
Last Name:KOLANDER
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 1:1018 E LOOP 304
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-1806
Mailing Address - Country:US
Mailing Address - Phone:936-545-2044
Mailing Address - Fax:936-546-0021
Practice Address - Street 1:1018 E LOOP 304
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1806
Practice Address - Country:US
Practice Address - Phone:936-545-2044
Practice Address - Fax:936-546-0021
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1067841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T3196OtherBCBS OF TEXAS
TX1039571OtherBLUELINK#
TX7336732OtherAETNA PIN #
TX8D9137Medicare PIN
TX1039571OtherBLUELINK#