Provider Demographics
NPI:1497775258
Name:KOOYENGA, DAVID J (PT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:KOOYENGA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25622 S GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-8987
Mailing Address - Country:US
Mailing Address - Phone:708-460-9836
Mailing Address - Fax:708-460-1117
Practice Address - Street 1:25622 S GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-8987
Practice Address - Country:US
Practice Address - Phone:708-235-0144
Practice Address - Fax:708-235-0145
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K13354Medicare PIN