Healthcare Provider Details

I. General information

NPI: 1205171881
Provider Name (Legal Business Name): SUBIN JOSE PUTHENKANDAM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5745 S UNIVERSITY DR
DAVIE FL
33328-6114
US

IV. Provider business mailing address

321 E SHERIDAN ST APT 307
DANIA BEACH FL
33004-5571
US

V. Phone/Fax

Practice location:
  • Phone: 954-252-9619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27872
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: