Provider Demographics
NPI:1447709563
Name:TELFER, JOSHUA (DPT)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:TELFER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2361 ISABELLA DR
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-4475
Mailing Address - Country:US
Mailing Address - Phone:636-359-2188
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012281A225100000X
IDPT-4743225100000X
MO2016032977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGOtherANTHEM PROVIDER NUMBER - TIN 35-2030653
INPENDINGMedicaid
INPENDINGMedicaid