Provider Demographics
NPI:1124116546
Name:STODDARD, JONATHAN DOUGLAS (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DOUGLAS
Last Name:STODDARD
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 1:5541 MURTON PL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-3763
Mailing Address - Country:US
Mailing Address - Phone:817-514-9127
Mailing Address - Fax:
Practice Address - Street 1:1940 BEDFORD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5707
Practice Address - Country:US
Practice Address - Phone:817-283-9435
Practice Address - Fax:817-571-4198
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1161585225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00322YMedicare ID - Type UnspecifiedDALLAS GROUP NUMBER
TX00129YMedicare ID - Type UnspecifiedTARRANT GROUP MEDICARE
TX8D7404Medicare ID - Type UnspecifiedTARRANT MEDICARE
TX8D7405Medicare ID - Type UnspecifiedDALLAS MEDICARE
TX1194727446Medicare ID - Type UnspecifiedBEDFORD GROUP NPI
TX1821090069Medicare ID - Type UnspecifiedIRVING NPI