Provider Demographics
NPI:1659754703
Name:GUVVALA, UDAY KIRAN (PT)
Entity Type:Individual
Prefix:
First Name:UDAY KIRAN
Middle Name:
Last Name:GUVVALA
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 1:1911 SPRINGPORT RD
Mailing Address - Street 2:APARTMENT 8
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1457
Mailing Address - Country:US
Mailing Address - Phone:408-613-7793
Mailing Address - Fax:
Practice Address - Street 1:110 N ELM AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3571
Practice Address - Country:US
Practice Address - Phone:517-787-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist