Provider Demographics
NPI:1093220691
Name:GEORGE, NIBU KOSHY (RPT)
Entity Type:Individual
Prefix:
First Name:NIBU
Middle Name:KOSHY
Last Name:GEORGE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N COPPELL RD APT 4204
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2055
Mailing Address - Country:US
Mailing Address - Phone:586-744-9042
Mailing Address - Fax:
Practice Address - Street 1:680 N WATTERS RD
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5126
Practice Address - Country:US
Practice Address - Phone:596-744-9042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1286050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist