Provider Demographics
NPI:1205171881
Name:PUTHENKANDAM, SUBIN JOSE (PT)
Entity type:Individual
Prefix:
First Name:SUBIN
Middle Name:JOSE
Last Name:PUTHENKANDAM
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 1:321 E SHERIDAN ST
Mailing Address - Street 2:APT 307
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-5571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5745 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-6114
Practice Address - Country:US
Practice Address - Phone:954-252-9619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27872225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist