Basic Information
| Provider Information | |||||||||
| NPI: | 1811402522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLUBOTHU | ||||||||
| FirstName: | SUPRITHA | ||||||||
| MiddleName: | NAGARAJ | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 ROCKLAND RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2017 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | J1-0003583 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.