Provider Demographics
NPI:1215174289
Name:KRISHNAMOORTHI, KUMAR (PT)
Entity type:Individual
Prefix:
First Name:KUMAR
Middle Name:
Last Name:KRISHNAMOORTHI
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 1:25 AVALON RD
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1401
Mailing Address - Country:US
Mailing Address - Phone:516-837-0356
Mailing Address - Fax:516-837-0356
Practice Address - Street 1:25 AVALON RD
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1401
Practice Address - Country:US
Practice Address - Phone:516-837-0356
Practice Address - Fax:516-837-0356
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015503-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker