Provider Demographics
NPI:1124068374
Name:DUTTWEILER, RICHARD (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DUTTWEILER
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 1:1040 SIERRA DR
Mailing Address - Street 2:STE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-865-8540
Mailing Address - Fax:317-865-8317
Practice Address - Street 1:759 45TH AVE
Practice Address - Street 2:STE. 202
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2939
Practice Address - Country:US
Practice Address - Phone:219-836-0193
Practice Address - Fax:219-836-2452
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001602A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200530270Medicaid