Provider Demographics
NPI:1073778486
Name:NULLWALA, MUBARAKA MOIEZ (PT)
Entity Type:Individual
Prefix:MS
First Name:MUBARAKA
Middle Name:MOIEZ
Last Name:NULLWALA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1275
Mailing Address - Country:US
Mailing Address - Phone:201-339-0021
Mailing Address - Fax:732-738-4248
Practice Address - Street 1:8845 19TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-6008
Practice Address - Country:US
Practice Address - Phone:718-449-9819
Practice Address - Fax:718-975-7521
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist