Basic Information
| Provider Information | |||||||||
| NPI: | 1477852358 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSE | ||||||||
| FirstName: | SUJA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| OtherLastName: | JOSE | ||||||||
| OtherFirstName: | SUJA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106055224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888304125 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 456 PROSPECT AVE STE C | ||||||||
| Address2: | |||||||||
| City: | WEST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070524112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736515000 | ||||||||
| FaxNumber: | 9736515001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2011 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01277100 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.