Provider Demographics
NPI:1972874592
Name:MAMPALLIL, JOSEPH K (RPT)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:K
Last Name:MAMPALLIL
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 LAKE SHORE RANCH DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-5562
Mailing Address - Country:US
Mailing Address - Phone:813-684-9618
Mailing Address - Fax:
Practice Address - Street 1:1465 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4854
Practice Address - Country:US
Practice Address - Phone:813-655-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist