Provider Demographics
NPI:1689178642
Name:BILOTTA, DAVID JON
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JON
Last Name:BILOTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1802
Mailing Address - Country:US
Mailing Address - Phone:734-244-2657
Mailing Address - Fax:
Practice Address - Street 1:200 SAND CREEK HWY
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1255
Practice Address - Country:US
Practice Address - Phone:517-263-6794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003145225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant