Basic Information
Provider Information | |||||||||
NPI: | 1871924985 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALIWAD | ||||||||
FirstName: | POOLATSYA | ||||||||
MiddleName: | GIRISHBHAI | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3111 HONEYWOOD LN | ||||||||
Address2: | APT-G | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240188871 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5515805281 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 22960 SHAW RD | ||||||||
Address2: | SUITE 605 | ||||||||
City: | STERLING | ||||||||
State: | VA | ||||||||
PostalCode: | 201669447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107509006 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2013 | ||||||||
LastUpdateDate: | 11/29/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305207804 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.