Provider Demographics
NPI:1750738332
Name:THOTAKURA, VIDYA
Entity type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:THOTAKURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3867 WILDER RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2365
Mailing Address - Country:US
Mailing Address - Phone:989-460-0020
Mailing Address - Fax:989-460-0021
Practice Address - Street 1:3867 WILDER RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2365
Practice Address - Country:US
Practice Address - Phone:989-460-0020
Practice Address - Fax:989-460-0021
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist