Provider Demographics
NPI:1194797506
Name:KAUTZMANN, DEREK KARL (MPT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:KARL
Last Name:KAUTZMANN
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 1:6350 GLENWAY AVE
Mailing Address - Street 2:SUITE 415
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-6378
Mailing Address - Country:US
Mailing Address - Phone:513-347-9999
Mailing Address - Fax:513-347-3999
Practice Address - Street 1:6350 GLENWAY AVE
Practice Address - Street 2:SUITE 415
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-6378
Practice Address - Country:US
Practice Address - Phone:513-347-9999
Practice Address - Fax:513-347-3999
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010701174400000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH010701OtherOH PT LICENSE
OHH221740Medicare PIN
OH010701OtherOH PT LICENSE
KY0239486Medicare PIN