Provider Demographics
NPI:1285111856
Name:VARGHESE KIZHAKKEMURI, JERRY (PT)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:VARGHESE KIZHAKKEMURI
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 1:10817 GRECIAN DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-5783
Mailing Address - Country:US
Mailing Address - Phone:216-172-2297
Mailing Address - Fax:
Practice Address - Street 1:UT SOUTHWESTERN MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-0001
Practice Address - Country:US
Practice Address - Phone:214-633-4794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1195960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist