Provider Demographics
NPI:1245401470
Name:BETTS, KHADIM HUSSAIN (PT)
Entity Type:Individual
Prefix:
First Name:KHADIM
Middle Name:HUSSAIN
Last Name:BETTS
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 1:1020 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-4902
Mailing Address - Country:US
Mailing Address - Phone:631-842-2424
Mailing Address - Fax:
Practice Address - Street 1:152 ISLIP AVE
Practice Address - Street 2:STE. 15
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3225
Practice Address - Country:US
Practice Address - Phone:631-277-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-16
Last Update Date:2008-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022712-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist