Provider Demographics
NPI:1386790467
Name:RWAKONDA, INNOCENT URAYAI (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:INNOCENT
Middle Name:URAYAI
Last Name:RWAKONDA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1263
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:NJ
Mailing Address - Zip Code:07827-0263
Mailing Address - Country:US
Mailing Address - Phone:973-293-8351
Mailing Address - Fax:973-293-8351
Practice Address - Street 1:218A SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:NJ
Practice Address - Zip Code:07827-0263
Practice Address - Country:US
Practice Address - Phone:973-293-8351
Practice Address - Fax:973-293-8351
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT010414L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist