Basic Information
| Provider Information | |||||||||
| NPI: | 1538464318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUDGAL | ||||||||
| FirstName: | JAYANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12310 83RD AVE | ||||||||
| Address2: | APT 2A | ||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114153457 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3201 W COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547394247 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2011 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 032807 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.