Provider Demographics
NPI:1881846129
Name:MAHADEVAN, POOJA VINAY
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:VINAY
Last Name:MAHADEVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SENATOR ST
Mailing Address - Street 2:APT 2B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-5404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2310 65TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4088
Practice Address - Country:US
Practice Address - Phone:718-336-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist