Provider Demographics
NPI:1437292752
Name:CUMARASAMY, THAYALAN KRISHNA (MD)
Entity Type:Individual
Prefix:DR
First Name:THAYALAN
Middle Name:KRISHNA
Last Name:CUMARASAMY
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 1:1816 MOUNT HOLLY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-4718
Mailing Address - Country:US
Mailing Address - Phone:609-747-0870
Mailing Address - Fax:609-747-0877
Practice Address - Street 1:1816 MOUNT HOLLY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4718
Practice Address - Country:US
Practice Address - Phone:609-747-0870
Practice Address - Fax:609-747-0877
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA61656204E00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2149819OtherAETNA
NJ6547001Medicaid
NJG03284Medicare UPIN
NJ6547001Medicaid