Provider Demographics
NPI:1104153618
Name:MURUKESAN, DEEPA
Entity type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:MURUKESAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 34TH AVENUE A
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6602
Mailing Address - Country:US
Mailing Address - Phone:309-762-6808
Mailing Address - Fax:
Practice Address - Street 1:4810 34TH AVENUE A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6602
Practice Address - Country:US
Practice Address - Phone:309-762-6808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist