Provider Demographics
NPI:1164523023
Name:RADHAKRISHNAN, JOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOLLY
Middle Name:
Last Name:RADHAKRISHNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MORNINGSIDE DR
Mailing Address - Street 2:APT 52
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1719
Mailing Address - Country:US
Mailing Address - Phone:212-666-2371
Mailing Address - Fax:
Practice Address - Street 1:1111 AMSTERDAM AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1716
Practice Address - Country:US
Practice Address - Phone:718-960-1411
Practice Address - Fax:718-518-5124
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198130208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01605536Medicaid
G08611Medicare UPIN
NY01605536Medicaid