Provider Demographics
NPI:1609341619
Name:OBRA, EDSEL D (PT)
Entity Type:Individual
Prefix:
First Name:EDSEL
Middle Name:D
Last Name:OBRA
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 1:37764 IRENE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-1934
Mailing Address - Country:US
Mailing Address - Phone:586-722-4735
Mailing Address - Fax:586-264-8525
Practice Address - Street 1:37764 IRENE DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-1934
Practice Address - Country:US
Practice Address - Phone:586-722-4735
Practice Address - Fax:586-264-8525
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011778225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist