Provider Demographics
NPI:1265703425
Name:SURYAMONI, MALLIKARJUNA PRASAD (PT)
Entity type:Individual
Prefix:
First Name:MALLIKARJUNA
Middle Name:PRASAD
Last Name:SURYAMONI
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 1:3515 SABLE PALM LN UNIT L
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5581
Mailing Address - Country:US
Mailing Address - Phone:618-402-8723
Mailing Address - Fax:
Practice Address - Street 1:1550 JESS PARRISH CT
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2147
Practice Address - Country:US
Practice Address - Phone:321-269-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25836225100000X
IN0500977A225100000X
MI5501013526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist