Provider Demographics
NPI:1598032302
Name:PAULOSE, PAUL MATTAMANA
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:MATTAMANA
Last Name:PAULOSE
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 1:3311 TIMBER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-3534
Mailing Address - Country:US
Mailing Address - Phone:630-566-0265
Mailing Address - Fax:
Practice Address - Street 1:2100 S FINLEY RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4830
Practice Address - Country:US
Practice Address - Phone:630-495-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005168225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant