Provider Demographics
NPI:1396024972
Name:MYDAM, JANARDHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JANARDHAN
Middle Name:
Last Name:MYDAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 BEAUBIEN ST
Mailing Address - Street 2:3T72
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-745-5533
Mailing Address - Fax:
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03613072208000000X, 208M00000X
IL0361330722080N0001X
IL036-133072208000000X
MI4301095991208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine