Provider Demographics
NPI:1689786303
Name:MIELKE, THOMAS BRIAN (DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BRIAN
Last Name:MIELKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 CYNWOOD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3805
Mailing Address - Country:US
Mailing Address - Phone:410-770-9720
Mailing Address - Fax:410-770-9725
Practice Address - Street 1:598 CYNWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3805
Practice Address - Country:US
Practice Address - Phone:410-770-9720
Practice Address - Fax:410-770-9725
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD62115901OtherBCBS
MD359MH265Medicare ID - Type Unspecified
MDQ03110Medicare UPIN