Provider Demographics
NPI:1730213752
Name:DEROOS, OLAF (PT)
Entity type:Individual
Prefix:
First Name:OLAF
Middle Name:
Last Name:DEROOS
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:PO BOX 21150
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-4150
Mailing Address - Country:US
Mailing Address - Phone:303-546-9158
Mailing Address - Fax:303-546-9107
Practice Address - Street 1:4150 DARLEY AVE STE 8
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6537
Practice Address - Country:US
Practice Address - Phone:303-494-4100
Practice Address - Fax:303-494-0212
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC459858Medicare PIN
COC495848Medicare PIN