Provider Demographics
NPI:1982761177
Name:JODER, DUSTIN (PT)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:JODER
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 1:2414 W RENWICK RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-0000
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:25445 S PHEASANT LN
Practice Address - Street 2:UNIT H
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-8838
Practice Address - Country:US
Practice Address - Phone:815-521-0111
Practice Address - Fax:815-521-0222
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-012130OtherPT STATE LICENSE #
IL146636Medicare ID - Type Unspecified