MEDICARE: NETRA L SUKHATANKAR O.T.

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	174400000X	Specialist	112409	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	112409	OTHER	TX	OCCUPATIONAL THERAPY LICENSE

General Provider Information

NPI Number	:	1881821106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NETRA L SUKHATANKAR O.T.

Provider Business Mailing Address
First Line	:	501 S AUSTIN AVE
Second Line	:	#1310
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-5610
Country	:	US
Telephone Number	:	512-864-6054
Fax Number	:	512-869-8157

Provider Business Practice Location Address
First Line	:	501 S AUSTIN AVE
Second Line	:	#1310
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-5610
Country	:	US
Telephone Number	:	512-864-6054
Fax Number	:	512-869-8157

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

Provider Enumeration Date	:	06/12/2009
Last Update Date	:	06/12/2009

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