Provider Demographics
NPI:1083001234
Name:TIRTAPUTRA, EVAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:TIRTAPUTRA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:137 W HIGH ST STE 3
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921
Practice Address - Country:US
Practice Address - Phone:410-392-7027
Practice Address - Fax:410-392-5768
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3844225100000X
MD27800225100000X
DEJ1-0003931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist