Provider Demographics
NPI:1427091487
Name:SOUKUP, JOHN (PT, MTC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SOUKUP
Suffix:
Gender:M
Credentials:PT, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2170
Mailing Address - Country:US
Mailing Address - Phone:541-269-7212
Mailing Address - Fax:541-267-5260
Practice Address - Street 1:1650 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2170
Practice Address - Country:US
Practice Address - Phone:541-269-7212
Practice Address - Fax:541-267-5260
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266520Medicare ID - Type UnspecifiedPROVIDER NUMBER
OR386514Medicare PIN