Provider Demographics
NPI:1679552343
Name:WITHERELL, WINSTON RYDER (PT)
Entity type:Individual
Prefix:MR
First Name:WINSTON
Middle Name:RYDER
Last Name:WITHERELL
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 1:300 TUSKEGEE BLVD
Mailing Address - Street 2:436 MEDICAL GROUP
Mailing Address - City:DOVER AFB
Mailing Address - State:DE
Mailing Address - Zip Code:19902-5003
Mailing Address - Country:US
Mailing Address - Phone:302-677-2568
Mailing Address - Fax:302-677-2540
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:436 MEDICAL GROUP
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902-5003
Practice Address - Country:US
Practice Address - Phone:302-677-2568
Practice Address - Fax:302-677-2540
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN