Provider Demographics
NPI:1225651334
Name:VISWANATHAN, SRIRAM
Entity Type:Individual
Prefix:
First Name:SRIRAM
Middle Name:
Last Name:VISWANATHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 LEXINGTON AVE APT 21H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2932
Mailing Address - Country:US
Mailing Address - Phone:917-593-1101
Mailing Address - Fax:
Practice Address - Street 1:4713 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3209
Practice Address - Country:US
Practice Address - Phone:646-461-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist