MEDICARE: VIDYA THOTAKURA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501011817	MI

General Provider Information

NPI Number	:	1750738332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIDYA THOTAKURA

Provider Business Mailing Address
First Line	:	3867 WILDER RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2365
Country	:	US
Telephone Number	:	989-460-0020
Fax Number	:	989-460-0021

Provider Business Practice Location Address
First Line	:	3867 WILDER RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2365
Country	:	US
Telephone Number	:	989-460-0020
Fax Number	:	989-460-0021

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2016
Last Update Date	:	05/24/2016

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Directions to “ VIDYA THOTAKURA ” Practice Location

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