Provider Demographics
NPI:1881668226
Name:LACOBOULOS, JOHN H (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:LACOBOULOS
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 1:1401 CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:EDDYSTONE
Mailing Address - State:PA
Mailing Address - Zip Code:19022-1336
Mailing Address - Country:US
Mailing Address - Phone:866-557-9430
Mailing Address - Fax:866-557-9431
Practice Address - Street 1:1401 CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:EDDYSTONE
Practice Address - State:PA
Practice Address - Zip Code:19022-1336
Practice Address - Country:US
Practice Address - Phone:866-557-9430
Practice Address - Fax:866-557-9431
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013028L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017783000OtherIBC
PA001952664-0003Medicaid
PA1952664Medicaid
PA338203OtherHIGHMARK BLUE SHIELD
PA034851YE4EMedicare PIN
PA034851NU9Medicare ID - Type Unspecified
PA001952664-0003Medicaid