Provider Demographics
NPI:1316351588
Name:DELLWO, TIMOTHY DAVID (DPT)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DAVID
Last Name:DELLWO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 1ST ST N APT 204
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-7376
Mailing Address - Country:US
Mailing Address - Phone:318-918-6895
Mailing Address - Fax:
Practice Address - Street 1:3901 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4312
Practice Address - Country:US
Practice Address - Phone:904-345-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist