Provider Demographics
NPI:1083902399
Name:MUTHUKANAGARAJ, PURUSHOTHAMAN (MD)
Entity Type:Individual
Prefix:
First Name:PURUSHOTHAMAN
Middle Name:
Last Name:MUTHUKANAGARAJ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10-42 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-1617
Mailing Address - Country:US
Mailing Address - Phone:607-762-2990
Mailing Address - Fax:
Practice Address - Street 1:1042 MITCHELL AVE # 42
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1678
Practice Address - Country:US
Practice Address - Phone:607-762-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01168207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083902399Medicaid
NC19LTGOtherBCBS OF NC
NC1083902399Medicaid