Provider Demographics
NPI:1225453673
Name:BONTHA, SRINIVAS
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:BONTHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HAMPTON CIR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4195
Mailing Address - Country:US
Mailing Address - Phone:248-289-1127
Mailing Address - Fax:
Practice Address - Street 1:130 HAMPTON CIR
Practice Address - Street 2:SUITE 150
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4195
Practice Address - Country:US
Practice Address - Phone:248-289-1127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist