Provider Demographics
NPI:1184762460
Name:MIRJAT, MUBARAK (PT)
Entity type:Individual
Prefix:MR
First Name:MUBARAK
Middle Name:
Last Name:MIRJAT
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 1:12021 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1139
Mailing Address - Country:US
Mailing Address - Phone:708-923-1768
Mailing Address - Fax:708-923-1773
Practice Address - Street 1:12021 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1139
Practice Address - Country:US
Practice Address - Phone:708-923-1768
Practice Address - Fax:708-923-1773
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004757A225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN156607Medicare ID - Type Unspecified
IL146641Medicare ID - Type Unspecified