Provider Demographics
NPI:1568146207
Name:STOCKHAUSEN, DAVID JOHN JR (DPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:STOCKHAUSEN
Suffix:JR
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 1:19540 BOWRING PARK RD APT 104
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-5247
Mailing Address - Country:US
Mailing Address - Phone:239-634-2648
Mailing Address - Fax:
Practice Address - Street 1:26850 S BAY DR
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4379
Practice Address - Country:US
Practice Address - Phone:239-948-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2024-05-22
Deactivation Date:2024-04-22
Deactivation Code:
Reactivation Date:2024-05-10
Provider Licenses
StateLicense IDTaxonomies
FLPT40371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist