Provider Demographics
NPI:1083807796
Name:PUNNIYAKOTTI, ANBU (PT)
Entity Type:Individual
Prefix:
First Name:ANBU
Middle Name:
Last Name:PUNNIYAKOTTI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49628 GREAT FALLS RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-3459
Mailing Address - Country:US
Mailing Address - Phone:734-397-2830
Mailing Address - Fax:734-397-4918
Practice Address - Street 1:49628 GREAT FALLS RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-3459
Practice Address - Country:US
Practice Address - Phone:734-397-2830
Practice Address - Fax:734-397-4918
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-26
Last Update Date:2007-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI65-O-H2-2460-0OtherBCBS
MI0P13620Medicare PIN