Provider Demographics
NPI:1366505372
Name:JANARDHANA MAHADEVA
Entity Type:Organization
Organization Name:JANARDHANA MAHADEVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANARDHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHADEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-746-6467
Mailing Address - Street 1:174 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:NY
Mailing Address - Zip Code:13753
Mailing Address - Country:US
Mailing Address - Phone:607-746-6467
Mailing Address - Fax:607-746-6465
Practice Address - Street 1:174 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:NY
Practice Address - Zip Code:13753
Practice Address - Country:US
Practice Address - Phone:607-746-6467
Practice Address - Fax:607-746-6465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00538629Medicaid
C07988Medicare UPIN
NY00538629Medicaid