Healthcare Provider Details

I. General information

NPI: 1588926315
Provider Name (Legal Business Name): LAKSHMI CHARITHA JIDUGU PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ADAM CLAYTON POWELL JR BLVD
NEW YORK NY
10026-1723
US

IV. Provider business mailing address

174 GRAND ST
WHITE PLAINS NY
10601-4803
US

V. Phone/Fax

Practice location:
  • Phone: 212-864-1500
  • Fax: 212-864-0500
Mailing address:
  • Phone: 914-328-8077
  • Fax: 914-328-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number030712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: