Provider Demographics
NPI:1598806473
Name:BRANDT, JOHN (DPT, ATC LAT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BRANDT
Suffix:
Gender:M
Credentials:DPT, ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-296-2223
Practice Address - Street 1:2410 E 7TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1961
Practice Address - Country:US
Practice Address - Phone:712-243-2267
Practice Address - Fax:712-243-2671
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI19172029Medicare PIN
IAIB3481008Medicare PIN
IAIB1213Medicare PIN
IAIB3481Medicare PIN
IAIB1212035Medicare PIN
IAI19172Medicare PIN
IAIB1212Medicare PIN
IAIB1213036Medicare PIN