Healthcare Provider Details

I. General information

NPI: 1538464318
Provider Name (Legal Business Name): JAYANT MUDGAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W COMMERCIAL BLVD SUITE 116
FORT LAUDERDALE FL
33309-3440
US

IV. Provider business mailing address

12310 83RD AVE APT 2A
KEW GARDENS NY
11415-3457
US

V. Phone/Fax

Practice location:
  • Phone: 954-739-4247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number032807
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: