Provider Demographics
NPI:1346558350
Name:VISWA NATHAN MD LLC
Entity Type:Organization
Organization Name:VISWA NATHAN MD LLC
Other - Org Name:VISWA NATHAN MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VISWA
Authorized Official - Middle Name:
Authorized Official - Last Name:NATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-946-3000
Mailing Address - Street 1:136 SHERMAN AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5238
Mailing Address - Country:US
Mailing Address - Phone:203-946-3000
Mailing Address - Fax:203-946-3006
Practice Address - Street 1:136 SHERMAN AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5238
Practice Address - Country:US
Practice Address - Phone:203-946-3000
Practice Address - Fax:203-946-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022726305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization