Provider Demographics
NPI:1366621294
Name:KRISHNAMOORTHY, MADHAVAN (PT)
Entity type:Individual
Prefix:
First Name:MADHAVAN
Middle Name:
Last Name:KRISHNAMOORTHY
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 1:7460 DRY CREEK DR
Mailing Address - Street 2:APT 2A
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-6313
Mailing Address - Country:US
Mailing Address - Phone:810-265-3882
Mailing Address - Fax:810-963-0560
Practice Address - Street 1:7460 DRY CREEK DR
Practice Address - Street 2:APT 2A
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-6313
Practice Address - Country:US
Practice Address - Phone:810-265-3882
Practice Address - Fax:810-963-0560
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-27
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501007308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist