Provider Demographics
NPI:1619192150
Name:VAN SUSTEREN, JOHN R (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:VAN SUSTEREN
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 1:800 GENEVA PKWY N
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-5701
Mailing Address - Country:US
Mailing Address - Phone:262-248-9902
Mailing Address - Fax:262-248-9419
Practice Address - Street 1:800 GENEVA PKWY N
Practice Address - Street 2:SUITE 3
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-5701
Practice Address - Country:US
Practice Address - Phone:262-248-9902
Practice Address - Fax:262-248-9419
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4467024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40316500Medicaid
WI11413052OtherCAQH
WI$$$$$$$$$004OtherBCBS
WIS65244Medicare UPIN
WI000186657Medicare ID - Type Unspecified