Provider Demographics
NPI:1124395512
Name:MAKDISI, EVE SERENA VALERIE (PT)
Entity Type:Individual
Prefix:
First Name:EVE
Middle Name:SERENA VALERIE
Last Name:MAKDISI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:EVE
Other - Middle Name:
Other - Last Name:ARCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3872 SHAFTER AVE APT A
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2629
Mailing Address - Country:US
Mailing Address - Phone:707-704-4137
Mailing Address - Fax:
Practice Address - Street 1:3872 SHAFTER AVE APT A
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2629
Practice Address - Country:US
Practice Address - Phone:707-704-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist