Provider Demographics
NPI:1609063908
Name:PUTLUR, PRAVEEN (MS, PT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:PRAVEEN
Middle Name:
Last Name:PUTLUR
Suffix:
Gender:M
Credentials:MS, PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 ENCHANTED FOREST ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-4756
Mailing Address - Country:US
Mailing Address - Phone:312-502-0206
Mailing Address - Fax:
Practice Address - Street 1:111 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1994
Practice Address - Country:US
Practice Address - Phone:574-647-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008806A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic