Provider Demographics
NPI:1770671299
Name:OOSTHOEK, KORNELIS (PT)
Entity Type:Individual
Prefix:
First Name:KORNELIS
Middle Name:
Last Name:OOSTHOEK
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 1:1247 CASTLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-3720
Mailing Address - Country:US
Mailing Address - Phone:248-673-6980
Mailing Address - Fax:248-673-7497
Practice Address - Street 1:2050 N HAGGERTY RD STE 280
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3796
Practice Address - Country:US
Practice Address - Phone:734-844-0800
Practice Address - Fax:734-844-0808
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F324550OtherBLUE CROSS OF MICHIGAN
MIP12180001Medicare ID - Type Unspecified