Provider Demographics
NPI:1306404652
Name:JOHN, TITUS MATHEW
Entity Type:Individual
Prefix:
First Name:TITUS
Middle Name:MATHEW
Last Name:JOHN
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 1:1959 BEECH LANE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1708
Mailing Address - Country:US
Mailing Address - Phone:248-225-9742
Mailing Address - Fax:
Practice Address - Street 1:1959 BEECH LANE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1708
Practice Address - Country:US
Practice Address - Phone:248-225-9742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005806225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant