Provider Demographics
NPI:1235238031
Name:MUDUMBA, SHANTI (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANTI
Middle Name:
Last Name:MUDUMBA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 WESTLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-2424
Mailing Address - Country:US
Mailing Address - Phone:516-536-0092
Mailing Address - Fax:516-908-4588
Practice Address - Street 1:2524 WESTLAKE AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-2424
Practice Address - Country:US
Practice Address - Phone:516-536-0092
Practice Address - Fax:516-908-4588
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022753-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQT1151Medicare UPIN