Provider Demographics
NPI:1760884308
Name:PUSULURI, RAJENDRA
Entity Type:Individual
Prefix:
First Name:RAJENDRA
Middle Name:
Last Name:PUSULURI
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 1:1115 MADISON ST NE # 1070
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7862
Mailing Address - Country:US
Mailing Address - Phone:503-560-2068
Mailing Address - Fax:
Practice Address - Street 1:1249 FAIRVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2534
Practice Address - Country:US
Practice Address - Phone:503-560-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWAPT60111357225100000X
OR63619261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist