Provider Demographics
NPI:1043241797
Name:MULLAMITHAWALA, FAYEZA F (PT)
Entity Type:Individual
Prefix:
First Name:FAYEZA
Middle Name:F
Last Name:MULLAMITHAWALA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:587 KINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2319
Mailing Address - Country:US
Mailing Address - Phone:650-868-8286
Mailing Address - Fax:
Practice Address - Street 1:1740 MARCO POLO WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4522
Practice Address - Country:US
Practice Address - Phone:650-552-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0281540OtherBLUE SHIELD ID NUMBER
CAPT28154OtherPT LICENSE NUMBER
CAOPT281540Medicare ID - Type UnspecifiedMEDICARE ID NUMBER