Provider Demographics
NPI:1568558120
Name:WINWARD, DOUGLAS (PT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:WINWARD
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 1:697 SOUTH 2600 EAST
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263
Mailing Address - Country:US
Mailing Address - Phone:208-852-0586
Mailing Address - Fax:208-852-0116
Practice Address - Street 1:43 NORTH 100 EAST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263
Practice Address - Country:US
Practice Address - Phone:208-852-0116
Practice Address - Fax:208-852-0116
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1652982Medicare ID - Type Unspecified
IDS99494Medicare UPIN