Provider Demographics
NPI:1477253623
Name:FOTINOPOULOS, ANGELO JAMES (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:JAMES
Last Name:FOTINOPOULOS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 LAKEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4981
Mailing Address - Country:US
Mailing Address - Phone:253-906-4260
Mailing Address - Fax:
Practice Address - Street 1:851 PENNIMAN AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1621
Practice Address - Country:US
Practice Address - Phone:877-864-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501302555OtherPT LICENSE