Provider Demographics
NPI:1063096402
Name:MADUWUBA, CHARLES U (PT, MHSPT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:U
Last Name:MADUWUBA
Suffix:
Gender:M
Credentials:PT, MHSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 E COLUMBINE LN
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-9741
Mailing Address - Country:US
Mailing Address - Phone:317-590-0244
Mailing Address - Fax:
Practice Address - Street 1:142 E COLUMBINE LN
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-9741
Practice Address - Country:US
Practice Address - Phone:317-590-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003539A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist