Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 043684-1 | NY |
N | 2251X0800X | Physical Therapist - Orthopedic | 043684-1 | NY |
NPI | 1033689781 |
---|---|
Provider Name | Dr. Mithun Mamoottil Abraham |
First Address | Great Neck, NY 11021-4802 |
Second Address | Great Neck, NY 11021 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/11/2018 |
Last Update Date | 17/10/2019 |