Provider Demographics
NPI:1477079614
Name:KADIYAM, VISWESWARA SASTRY
Entity Type:Individual
Prefix:
First Name:VISWESWARA
Middle Name:SASTRY
Last Name:KADIYAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 216TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1335
Mailing Address - Country:US
Mailing Address - Phone:973-930-2810
Mailing Address - Fax:
Practice Address - Street 1:688 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2622
Practice Address - Country:US
Practice Address - Phone:973-278-2207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039187-11835P0018X
NJ28RI022511001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist