Provider Demographics
NPI:1558317586
Name:ULLAL, SHYAM SUKUMAR (PT)
Entity Type:Individual
Prefix:MR
First Name:SHYAM
Middle Name:SUKUMAR
Last Name:ULLAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3674
Mailing Address - Country:US
Mailing Address - Phone:760-357-8864
Mailing Address - Fax:760-357-8866
Practice Address - Street 1:408 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2854
Practice Address - Country:US
Practice Address - Phone:760-357-8864
Practice Address - Fax:760-357-8866
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT014230Medicaid
CA5716132OtherPIN
CAW14493Medicare ID - Type Unspecified
CAPT014230Medicaid