Provider Demographics
NPI:1952393068
Name:MALLERS, DOUGLAS J (PT)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:MALLERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9602 COLDWATER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2095
Mailing Address - Country:US
Mailing Address - Phone:260-489-9887
Mailing Address - Fax:260-489-9121
Practice Address - Street 1:9602 COLDWATER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2095
Practice Address - Country:US
Practice Address - Phone:260-489-9887
Practice Address - Fax:260-489-9121
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200374590AMedicaid
INR61478Medicare UPIN
IN188320AMedicare ID - Type Unspecified