Provider Demographics
NPI:1497780902
Name:SANNI, KAMALDEEN A (PHD; PT)
Entity Type:Individual
Prefix:
First Name:KAMALDEEN
Middle Name:A
Last Name:SANNI
Suffix:
Gender:M
Credentials:PHD; PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9914 HARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-2119
Mailing Address - Country:US
Mailing Address - Phone:202-210-8985
Mailing Address - Fax:301-809-6823
Practice Address - Street 1:9914 HARBOR AVE
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-2119
Practice Address - Country:US
Practice Address - Phone:202-210-8985
Practice Address - Fax:301-809-6823
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT2655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC491111Medicare ID - Type UnspecifiedPHYSICAL THERAPY