Provider Demographics
NPI:1053535385
Name:MOHANTY, SUBHASIS
Entity type:Individual
Prefix:MR
First Name:SUBHASIS
Middle Name:
Last Name:MOHANTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 W PIERSON RD
Mailing Address - Street 2:SUITE-2
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2411
Mailing Address - Country:US
Mailing Address - Phone:810-732-2252
Mailing Address - Fax:810-732-4303
Practice Address - Street 1:5245 W PIERSON RD
Practice Address - Street 2:SUITE-2
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-2411
Practice Address - Country:US
Practice Address - Phone:810-732-2252
Practice Address - Fax:810-732-4303
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4501335Medicaid
MI4501335Medicaid