Provider Demographics
NPI:1063524742
Name:ABOULIAN, KEIKHOSROW KAI (PT)
Entity type:Individual
Prefix:MR
First Name:KEIKHOSROW
Middle Name:KAI
Last Name:ABOULIAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BOKUM RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1500
Mailing Address - Country:US
Mailing Address - Phone:860-767-9035
Mailing Address - Fax:860-767-9015
Practice Address - Street 1:12 BOKUM RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1500
Practice Address - Country:US
Practice Address - Phone:860-767-9035
Practice Address - Fax:860-767-9015
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01723225100000X
CT008663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007057785Medicare PIN