Provider Demographics
NPI:1699051557
Name:KOITHARA, SANJU (BACHELORS IN PT)
Entity type:Individual
Prefix:MR
First Name:SANJU
Middle Name:
Last Name:KOITHARA
Suffix:
Gender:M
Credentials:BACHELORS IN PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 BALSAM WAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314
Mailing Address - Country:US
Mailing Address - Phone:248-797-0741
Mailing Address - Fax:586-797-9006
Practice Address - Street 1:2644 BALSAM WAY DRIVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314
Practice Address - Country:US
Practice Address - Phone:248-797-0741
Practice Address - Fax:586-797-9006
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist