Provider Demographics
NPI:1134232101
Name:VANDER WILT, TIMOTHY (MSPT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:VANDER WILT
Suffix:
Gender:M
Credentials:MSPT
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-7555
Mailing Address - Fax:515-643-7560
Practice Address - Street 1:800 E 1ST ST
Practice Address - Street 2:SUITE W270
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-2077
Practice Address - Country:US
Practice Address - Phone:515-643-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1456715Medicaid
IAI14734Medicare ID - Type Unspecified
IA1456715Medicaid