Provider Demographics
NPI:1801376272
Name:IMMEKUS, DANIEL MARK (PT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:IMMEKUS
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 1:6737 SUDBURY
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-2409
Mailing Address - Country:US
Mailing Address - Phone:361-779-4112
Mailing Address - Fax:
Practice Address - Street 1:6737 SUDBURY
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-2409
Practice Address - Country:US
Practice Address - Phone:361-779-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1155468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist