Provider Demographics
NPI:1033629092
Name:BODURTHA, RUSSELL J (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:BODURTHA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:292 SPIELMAN HWY
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06013-1727
Practice Address - Country:US
Practice Address - Phone:860-404-2924
Practice Address - Fax:860-404-2933
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist