Provider Demographics
NPI:1528550118
Name:ISREAL, MICHAEL DONOVAN (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DONOVAN
Last Name:ISREAL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 HARDEN STREET EXT STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6842
Mailing Address - Country:US
Mailing Address - Phone:803-509-6389
Mailing Address - Fax:803-509-6390
Practice Address - Street 1:3300 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4065
Practice Address - Country:US
Practice Address - Phone:803-787-3143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist