Provider Demographics
NPI:1982976866
Name:POTTUKALAM, ROBIN JOSEPH (DPT)
Entity Type:Individual
Prefix:MR
First Name:ROBIN
Middle Name:JOSEPH
Last Name:POTTUKALAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4945
Mailing Address - Country:US
Mailing Address - Phone:805-497-7829
Mailing Address - Fax:805-497-7839
Practice Address - Street 1:2550 WILLOW LN
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-4945
Practice Address - Country:US
Practice Address - Phone:805-497-7829
Practice Address - Fax:805-497-7839
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15770Medicare UPIN