Provider Demographics
NPI:1114292794
Name:CHAZHIKAT, JOSE CYRIAC (PT)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:CYRIAC
Last Name:CHAZHIKAT
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 1:345 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-2546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-2546
Practice Address - Country:US
Practice Address - Phone:248-291-5534
Practice Address - Fax:248-291-5536
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI26-2191246OtherTAX ID #