Provider Demographics
NPI:1215054721
Name:SOEKARDI, ISMANSJAH (PT)
Entity type:Individual
Prefix:
First Name:ISMANSJAH
Middle Name:
Last Name:SOEKARDI
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 1:953 COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2309
Mailing Address - Country:US
Mailing Address - Phone:831-688-1212
Mailing Address - Fax:
Practice Address - Street 1:6193 SOQUEL DRIVE
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003
Practice Address - Country:US
Practice Address - Phone:831-462-1212
Practice Address - Fax:831-462-1221
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT25843OtherCA PT LICENSE NUMBER