Provider Demographics
NPI:1366730137
Name:MALDONADO, DAVID (DPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MALDONADO
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:6601 220TH ST SW STE 1
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2166
Practice Address - Country:US
Practice Address - Phone:425-775-7274
Practice Address - Fax:425-775-0963
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009882A225100000X
TN9820225100000X
WAPT00008658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300002166Medicaid
IN000001077027OtherANTHEM PROVIDER NUMBER