Provider Demographics
NPI:1407929185
Name:MAHADEVAN G KRISHNAN, MD PC
Entity Type:Organization
Organization Name:MAHADEVAN G KRISHNAN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHADEVAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:KRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-901-8822
Mailing Address - Street 1:609 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5227
Mailing Address - Country:US
Mailing Address - Phone:732-901-8822
Mailing Address - Fax:732-367-2897
Practice Address - Street 1:609 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5227
Practice Address - Country:US
Practice Address - Phone:732-901-8822
Practice Address - Fax:732-367-2897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0458542086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDB3539OtherRAILROAD MEDICARE
NJ080616Medicare PIN
NJ542526Medicare ID - Type Unspecified
NJDB3539OtherRAILROAD MEDICARE