Healthcare Provider Details

I. General information

NPI: 1124452230
Provider Name (Legal Business Name): KOMAL KUMAR KUKKAR PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 101ST AVE
SOUTH RICHMOND HILL NY
11419-1247
US

IV. Provider business mailing address

130 TUERS AVE APT 130
JERSEY CITY NJ
07306-3216
US

V. Phone/Fax

Practice location:
  • Phone: 312-810-8455
  • Fax:
Mailing address:
  • Phone: 312-810-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number036783
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: