Provider Demographics
NPI:1609410729
Name:CHUKWU, THEODORE (PTA)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:CHUKWU
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 1:9817 HORACE HARDING EXPY APT 1K
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4224
Mailing Address - Country:US
Mailing Address - Phone:718-685-8432
Mailing Address - Fax:
Practice Address - Street 1:10017 23RD AVE
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11369-1305
Practice Address - Country:US
Practice Address - Phone:718-205-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007802225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant