Provider Demographics
NPI:1811933294
Name:DEOL, AMANDEEP KAUR (PT)
Entity type:Individual
Prefix:
First Name:AMANDEEP
Middle Name:KAUR
Last Name:DEOL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4277 MOCCASIN TRL
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4852
Mailing Address - Country:US
Mailing Address - Phone:770-926-6520
Mailing Address - Fax:770-926-1359
Practice Address - Street 1:120 STONEBRIDGE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-3767
Practice Address - Country:US
Practice Address - Phone:770-926-6520
Practice Address - Fax:770-926-1359
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0081302251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52704315004OtherBCBS DOUGLASVILLE LOCATIO
GA52704315002OtherBCBS MARIETTA LOCATION
GA52704315003OtherBCBS AUSTELL LOCATION
GA5274315001OtherBCBS WOODSTOCK LOCATION
GA65BBDFZMedicare ID - Type Unspecified
GAQ53808Medicare UPIN
GA52704315003OtherBCBS AUSTELL LOCATION