Provider Demographics
NPI:1336929082
Name:BASUKALA, BIMAL (PT)
Entity Type:Individual
Prefix:
First Name:BIMAL
Middle Name:
Last Name:BASUKALA
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 1:13888 ROYAL SADDLE DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-9040
Mailing Address - Country:US
Mailing Address - Phone:510-283-4823
Mailing Address - Fax:
Practice Address - Street 1:118 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3323
Practice Address - Country:US
Practice Address - Phone:317-844-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012716A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist