Provider Demographics
NPI:1821211954
Name:RASUL, GAMBRA
Entity Type:Individual
Prefix:
First Name:GAMBRA
Middle Name:
Last Name:RASUL
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 1:2214 KNOTTY PINE TRL
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48855-7801
Mailing Address - Country:US
Mailing Address - Phone:248-250-1237
Mailing Address - Fax:
Practice Address - Street 1:2214 KNOTTY PINE TRL
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48855-7801
Practice Address - Country:US
Practice Address - Phone:248-250-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501009119Medicaid
MI5501009119Medicaid