| Doctor Name: | REVANTH MOPURU |
| NPI Number: | 1114371275 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 5501013417 |
| Business Practice Address: | 2815 Northwind Dr East Lansing, MI - 488235003 |
| Business Phone Number: | 5173320817 |
| Business Fax Number: | |
| Mailing Address: | 6140 Hardy Ave Apt 11, EAST LANSING |
| State: | MI |
| Postal Code: | 488231589 |
| Phone Number: | 5736390181 |
| Fax Number: | |
| NPI Enumeration Date: | 04/14/2016 |
| NPI Last Update Date: | 04/14/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 5501013417 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |