Provider Demographics
NPI:1265580773
Name:WISOFF, DOUGLAS MERRILL (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:MERRILL
Last Name:WISOFF
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:MR
Other - First Name:DOUGLAS
Other - Middle Name:MERRILL
Other - Last Name:WISOFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 3602
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80307-3602
Mailing Address - Country:US
Mailing Address - Phone:303-499-2062
Mailing Address - Fax:
Practice Address - Street 1:1295 S BROADWAY ST
Practice Address - Street 2:SUITE B
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6768
Practice Address - Country:US
Practice Address - Phone:303-499-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3112OtherPHYSICAL THERAPY LICENSE