Provider Demographics
NPI:1023385465
Name:THETTU, DEEPAK
Entity Type:Individual
Prefix:MR
First Name:DEEPAK
Middle Name:
Last Name:THETTU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 DEVONSHIRE CIR
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-2665
Mailing Address - Country:US
Mailing Address - Phone:585-314-4731
Mailing Address - Fax:
Practice Address - Street 1:110 DEVONSHIRE CIR
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-2665
Practice Address - Country:US
Practice Address - Phone:585-314-4731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009482-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist