Provider Demographics
NPI:1174809057
Name:MAHADIK, TAMANNA ROHAN (PT)
Entity type:Individual
Prefix:
First Name:TAMANNA
Middle Name:ROHAN
Last Name:MAHADIK
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 1:1520 NUTMEG PL STE 111
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2557
Mailing Address - Country:US
Mailing Address - Phone:714-979-3500
Mailing Address - Fax:
Practice Address - Street 1:1520 NUTMEG PL STE 111
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2557
Practice Address - Country:US
Practice Address - Phone:714-979-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033803225100000X
CA301951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400131732Medicare PIN
NYA400058163Medicare PIN
NYA400058339Medicare PIN
NYA400069254Medicare PIN
NYA400059117Medicare PIN
NYA400059135Medicare PIN
NYA400058226Medicare PIN