Healthcare Provider Details

I. General information

NPI: 1962687822
Provider Name (Legal Business Name): SAJU IDICULA VARGHESE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 W PARK DR
OLD BETHPAGE NY
11804-1621
US

IV. Provider business mailing address

6 W PARK DR
OLD BETHPAGE NY
11804-1621
US

V. Phone/Fax

Practice location:
  • Phone: 347-642-1731
  • Fax:
Mailing address:
  • Phone: 347-642-1731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number028349
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: