Provider Demographics
NPI:1659841120
Name:PATANKAR, JALDIPKUMAR M
Entity Type:Individual
Prefix:
First Name:JALDIPKUMAR
Middle Name:M
Last Name:PATANKAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 SANDALWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-3028
Mailing Address - Country:US
Mailing Address - Phone:248-875-2995
Mailing Address - Fax:
Practice Address - Street 1:1663 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2169
Practice Address - Country:US
Practice Address - Phone:248-247-7019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist