Provider Demographics
NPI:1114080827
Name:LOGANATHAN, RAGHUNANDAN S (MD, FCCP)
Entity Type:Individual
Prefix:DR
First Name:RAGHUNANDAN
Middle Name:S
Last Name:LOGANATHAN
Suffix:
Gender:M
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MARCOTTE LN
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2424
Mailing Address - Country:US
Mailing Address - Phone:458-271-8659
Mailing Address - Fax:
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:973-777-7377
Practice Address - Fax:973-777-3806
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10658800207RP1001X
NY001962207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Not Answered207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02554534Medicaid
NYI04800Medicare UPIN
NY02554534Medicaid