Provider Demographics
NPI:1841335007
Name:DOMMERHOLT, JAN (MPT)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:
Last Name:DOMMERHOLT
Suffix:
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 1:7830 OLD GEORGETOWN RD
Mailing Address - Street 2:SUITE C-15
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2432
Mailing Address - Country:US
Mailing Address - Phone:301-656-5613
Mailing Address - Fax:301-656-6586
Practice Address - Street 1:7830 OLD GEORGETOWN RD
Practice Address - Street 2:SUITE C-15
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2432
Practice Address - Country:US
Practice Address - Phone:301-656-5613
Practice Address - Fax:301-656-6586
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD017275P70Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUM