Provider Demographics
NPI:1831240613
Name:WIGHT, DANIEL FRANK JR (MPT)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:FRANK
Last Name:WIGHT
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29528 6 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3671
Mailing Address - Country:US
Mailing Address - Phone:734-422-0802
Mailing Address - Fax:734-422-0873
Practice Address - Street 1:29528 6 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3671
Practice Address - Country:US
Practice Address - Phone:734-422-0802
Practice Address - Fax:734-422-0873
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236685Medicare ID - Type Unspecified