Provider Demographics
NPI:1710948757
Name:ZYLSTRA, EDO (DPT)
Entity Type:Individual
Prefix:DR
First Name:EDO
Middle Name:
Last Name:ZYLSTRA
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 1:5135 HIDE AWAY LN
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7373
Mailing Address - Country:US
Mailing Address - Phone:303-263-7041
Mailing Address - Fax:
Practice Address - Street 1:4676 32ND AVE STE C
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-8015
Practice Address - Country:US
Practice Address - Phone:616-263-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7515225100000X
MI5501016106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC803400Medicare PIN