Provider Demographics
NPI:1457445033
Name:SHANMUGHAM, REVATHI (MD)
Entity Type:Individual
Prefix:DR
First Name:REVATHI
Middle Name:
Last Name:SHANMUGHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 ABBIE CT
Mailing Address - Street 2:40 EISENHOWER DRIVE
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652
Mailing Address - Country:US
Mailing Address - Phone:352-238-5670
Mailing Address - Fax:
Practice Address - Street 1:40 EISENHOVER DRIVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:352-686-2972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA083980002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260037453OtherRAILROAD MEDICARE
FL51265OtherBC BS OF FL
FL044684000Medicaid
FL044684000Medicaid
FL51265OtherBC BS OF FL