Provider Demographics
NPI:1558553800
Name:DANIEL, DEJUAN J (PT)
Entity Type:Individual
Prefix:
First Name:DEJUAN
Middle Name:J
Last Name:DANIEL
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:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:AR
Mailing Address - Zip Code:71639-0887
Mailing Address - Country:US
Mailing Address - Phone:870-382-4818
Mailing Address - Fax:870-382-1048
Practice Address - Street 1:8811 HWY 65 SOUTH
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639-0887
Practice Address - Country:US
Practice Address - Phone:870-382-4818
Practice Address - Fax:870-382-1048
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist