Provider Demographics
NPI:1558740720
Name:HEISER, DEREK B (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:B
Last Name:HEISER
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:PO BOX 117345
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7345
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6489
Practice Address - Street 1:5393 ROOSEVELT BLVD STE 17
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-8424
Practice Address - Country:US
Practice Address - Phone:904-389-8570
Practice Address - Fax:904-389-8599
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30517225100000X
VA2305209392225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist