Provider Demographics
NPI:1720163249
Name:BOB, JOHN (DPT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOB
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 E PINE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5536
Mailing Address - Country:US
Mailing Address - Phone:209-463-5800
Mailing Address - Fax:209-463-5900
Practice Address - Street 1:10200 TRINITY PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7286
Practice Address - Country:US
Practice Address - Phone:209-451-3920
Practice Address - Fax:209-451-3902
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235232251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT300ZMedicare PIN