Provider Demographics
NPI:1629572805
Name:MUKKAMALLA, VISWANATHA R (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:VISWANATHA
Middle Name:R
Last Name:MUKKAMALLA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:41667 STEINBECK GLN
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2869
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17220 W 12 MILE RD STE 140
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2114
Practice Address - Country:US
Practice Address - Phone:248-281-3428
Practice Address - Fax:248-281-3478
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X
MI5501013960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist