Provider Demographics
NPI:1497017578
Name:SUMATRA, LEO TAGBAR
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:TAGBAR
Last Name:SUMATRA
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 1:13135 LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-2873
Mailing Address - Country:US
Mailing Address - Phone:615-554-9224
Mailing Address - Fax:
Practice Address - Street 1:13135 LEBANON RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-2873
Practice Address - Country:US
Practice Address - Phone:615-554-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT19652251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics