Basic Information
| Provider Information | |||||||||
| NPI: | 1992283766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4430 MISSOURI AVENUE | ||||||||
| Address2: | BOX #1267 | ||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735961707 | ||||||||
| FaxNumber: | 3218025811 | ||||||||
| Practice Location | |||||||||
| Address1: | 4430 MISSOURI AVENUE | ||||||||
| Address2: | BOX #1267 | ||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735960417 | ||||||||
| FaxNumber: | 3218025811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2018 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT33776 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.