Provider Demographics
NPI:1760956718
Name:BHAKTAVATSALA, SIVAKUMAR
Entity Type:Individual
Prefix:
First Name:SIVAKUMAR
Middle Name:
Last Name:BHAKTAVATSALA
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 1:127 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-3823
Mailing Address - Country:US
Mailing Address - Phone:201-830-7310
Mailing Address - Fax:
Practice Address - Street 1:8845 19TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-6008
Practice Address - Country:US
Practice Address - Phone:718-449-9819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-13
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist