Provider Demographics
NPI:1265419071
Name:ENDO, DOUGLAS KIYOSHI (LPT)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:KIYOSHI
Last Name:ENDO
Suffix:
Gender:M
Credentials:LPT
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 25537
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2655 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8542
Practice Address - Country:US
Practice Address - Phone:801-256-6430
Practice Address - Fax:801-256-6431
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT366833-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ35200Medicare UPIN