Provider Demographics
NPI:1770526667
Name:CHARBONEAU, DAN (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:CHARBONEAU
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4611
Mailing Address - Country:US
Mailing Address - Phone:580-436-3633
Mailing Address - Fax:580-436-2977
Practice Address - Street 1:511 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4611
Practice Address - Country:US
Practice Address - Phone:580-436-3633
Practice Address - Fax:580-436-2977
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$PMedicare PIN