Provider Demographics
NPI:1386704187
Name:WARD, MICHAEL TIMOTHY (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:WARD
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 1:1302 DEACON DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6405
Mailing Address - Country:US
Mailing Address - Phone:979-739-3940
Mailing Address - Fax:979-484-7221
Practice Address - Street 1:1302 DEACON DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6405
Practice Address - Country:US
Practice Address - Phone:979-739-3940
Practice Address - Fax:979-484-7221
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1130268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86496TOtherBLUE CROSS BLUE SHIELD
TX149305801Medicaid
TX1093121824OtherNPI: BUSINESS/CLINIC
TX1386404187OtherNPI
83799EMedicare ID - Type Unspecified
TX149305801Medicaid