Provider Demographics
NPI:1902860687
Name:HAMM, JOHN MARK (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:HAMM
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 490210
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-0210
Mailing Address - Country:US
Mailing Address - Phone:800-778-6623
Mailing Address - Fax:352-750-5029
Practice Address - Street 1:13940 N US HIGHWAY 441
Practice Address - Street 2:SUITE 702
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8908
Practice Address - Country:US
Practice Address - Phone:352-751-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8111OtherBLUE SHIELD PROV #