Provider Demographics
NPI:1770819658
Name:GATDULA, JOAHNES PUNAY
Entity Type:Individual
Prefix:MR
First Name:JOAHNES
Middle Name:PUNAY
Last Name:GATDULA
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:PO BOX 7005
Mailing Address - Street 2:14TH AND BROADWAY
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-7005
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-223-9945
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-223-9945
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008449225X00000X
ZZ974225X00000X
ZZOT4721225X00000X
ZZ237044225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist