Provider Demographics
NPI:1497799944
Name:DAVE, INDRAVADAN (MD)
Entity Type:Individual
Prefix:DR
First Name:INDRAVADAN
Middle Name:
Last Name:DAVE
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 1:2090 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4719
Mailing Address - Country:US
Mailing Address - Phone:513-352-7828
Mailing Address - Fax:
Practice Address - Street 1:2090 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4719
Practice Address - Country:US
Practice Address - Phone:513-352-7828
Practice Address - Fax:516-352-7827
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41876207P00000X, 207R00000X
NY109643208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C418760Medicaid
CAF74582Medicare UPIN
CA00C418760Medicaid