Provider Demographics
NPI:1265097273
Name:SOETAN, DAMILOLA (PT, DPT, AIB-PCON)
Entity type:Individual
Prefix:DR
First Name:DAMILOLA
Middle Name:
Last Name:SOETAN
Suffix:
Gender:F
Credentials:PT, DPT, AIB-PCON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 CHICKADEE DR
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7792
Mailing Address - Country:US
Mailing Address - Phone:346-270-0950
Mailing Address - Fax:
Practice Address - Street 1:3777 N FRONTAGE RD STE 100
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7696
Practice Address - Country:US
Practice Address - Phone:219-872-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist