Provider Demographics
NPI:1588093678
Name:PALLAPOTHULA, HAREESH
Entity type:Individual
Prefix:
First Name:HAREESH
Middle Name:
Last Name:PALLAPOTHULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10763 100TH ST
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-2634
Mailing Address - Country:US
Mailing Address - Phone:361-522-1658
Mailing Address - Fax:
Practice Address - Street 1:99 MOORE ST
Practice Address - Street 2:1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-3302
Practice Address - Country:US
Practice Address - Phone:718-387-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist