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General NPI Number Information
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NPI Number | 1184189151
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Entity Type | Individual
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Provider Name | THILAK PURUSHOTHAMAN PT
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Gender | Male
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Dates
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Enumeration Date | 02/04/2019
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Last Update Date | 02/04/2019
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Provider Practice Location Address
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Address Line | 5651 LIMESTONE RD
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City | WILMINGTON
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State | DE
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Zip | 19808-1217
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Country | US
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Telephone | 302-239-8583
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Fax |
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Provider Business Mailing Address
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Address Line | 57 GLENCOE DR
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City | NEWARK
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State | DE
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Zip | 19702-2056
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | J1-0002405
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License Number State | DE
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