Provider Demographics
NPI:1699761643
Name:BRONDYKE, DUGLAS J (PT)
Entity type:Individual
Prefix:
First Name:DUGLAS
Middle Name:J
Last Name:BRONDYKE
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 1:2300 53RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7565
Mailing Address - Country:US
Mailing Address - Phone:563-322-0971
Mailing Address - Fax:
Practice Address - Street 1:2900 S 25TH ST STE B2
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-7250
Practice Address - Country:US
Practice Address - Phone:563-278-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070004020225100000X
IA01266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01266OtherLICENSE
IAI18344Medicare PIN