Provider Demographics
NPI:1669495297
Name:VAN DE WOUW, WILLEM G (PT)
Entity Type:Individual
Prefix:
First Name:WILLEM
Middle Name:G
Last Name:VAN DE WOUW
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 1:8809 COMMODITY CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-9052
Mailing Address - Country:US
Mailing Address - Phone:407-363-3443
Mailing Address - Fax:407-363-9446
Practice Address - Street 1:8809 COMMODITY CIR STE 2
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9052
Practice Address - Country:US
Practice Address - Phone:407-363-3443
Practice Address - Fax:407-363-9446
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 0008391225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68-6652Medicare ID - Type Unspecified