Provider Demographics
NPI:1578159422
Name:EGHAREVBA, ODE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ODE
Middle Name:
Last Name:EGHAREVBA
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 1:100 BROADWAY UNIT 594
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-5013
Mailing Address - Country:US
Mailing Address - Phone:347-869-9798
Mailing Address - Fax:
Practice Address - Street 1:2747 CRESCENT ST STE 203
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3142
Practice Address - Country:US
Practice Address - Phone:347-869-9798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist