Healthcare Provider Details

I. General information

NPI: 1639241680
Provider Name (Legal Business Name): JOHN M ANDRAKA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HEALTH PROFESSIONS BLDG
MT PLEASANT MI
48859-0001
US

IV. Provider business mailing address

1101 HEALTH PROFESSIONS BLDG
MT PLEASANT MI
48859-0001
US

V. Phone/Fax

Practice location:
  • Phone: 989-774-3904
  • Fax:
Mailing address:
  • Phone: 989-774-3904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501014186
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: