Provider Demographics
NPI:1255159463
Name:BOODRAM, MARK (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BOODRAM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 5TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4367
Mailing Address - Country:US
Mailing Address - Phone:646-490-4002
Mailing Address - Fax:
Practice Address - Street 1:138 5TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4367
Practice Address - Country:US
Practice Address - Phone:646-490-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic