Provider Demographics
NPI:1063929842
Name:CHANDANSHIVE, PAUL BHUPAL (PT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:BHUPAL
Last Name:CHANDANSHIVE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1286
Mailing Address - Country:US
Mailing Address - Phone:989-343-9755
Mailing Address - Fax:989-343-9955
Practice Address - Street 1:105 W HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1286
Practice Address - Country:US
Practice Address - Phone:989-343-9755
Practice Address - Fax:989-343-9955
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist