Provider Demographics
NPI:1447407580
Name:VANGURU, JYOTHSNA (PT)
Entity Type:Individual
Prefix:
First Name:JYOTHSNA
Middle Name:
Last Name:VANGURU
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 1:4350 MADISON AVE APT 308
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1571
Mailing Address - Country:US
Mailing Address - Phone:701-212-6513
Mailing Address - Fax:
Practice Address - Street 1:4102 SHORE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2608
Practice Address - Country:US
Practice Address - Phone:317-347-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013357225100000X
IN05009328A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist