Provider Demographics
NPI:1912039900
Name:VENKATASWAMY, VISWANATHAN (PT)
Entity Type:Individual
Prefix:MR
First Name:VISWANATHAN
Middle Name:
Last Name:VENKATASWAMY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28105 DECLARATION RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2546
Mailing Address - Country:US
Mailing Address - Phone:248-449-7281
Mailing Address - Fax:313-894-7374
Practice Address - Street 1:5407 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-3033
Practice Address - Country:US
Practice Address - Phone:313-894-4106
Practice Address - Fax:313-894-7374
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007322225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N63600002Medicare ID - Type Unspecified