Provider Demographics
NPI:1710286356
Name:DOLER, DAMON (PT)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:DOLER
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:PO BOX 1205
Mailing Address - Street 2:
Mailing Address - City:CALHOUN CITY
Mailing Address - State:MS
Mailing Address - Zip Code:38916-1205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 HWY 9
Practice Address - Street 2:
Practice Address - City:BRUCE
Practice Address - State:MS
Practice Address - Zip Code:38915
Practice Address - Country:US
Practice Address - Phone:662-414-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist