Provider Demographics
NPI:1609002393
Name:SEDIQUE, MOHAMMED N (PTA)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:N
Last Name:SEDIQUE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4341 BIRCH STREET, SUITE #102
Mailing Address - Street 2:SELECTIVE REHAB
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-250-7870
Mailing Address - Fax:949-475-1003
Practice Address - Street 1:4341 BIRCH STREET, SUITE #102
Practice Address - Street 2:SELECTIVE REHAB
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-250-7870
Practice Address - Fax:949-475-1003
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5525225200000X
CAPT5525225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant