Provider Demographics
NPI:1770249674
Name:MULUGETA, MAYRON (DPT, PT)
Entity type:Individual
Prefix:
First Name:MAYRON
Middle Name:
Last Name:MULUGETA
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 BOULEVARD WAY
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 BOULEVARD WAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610
Practice Address - Country:US
Practice Address - Phone:510-922-8872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
VACP008395T225100000X
CA303379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist