Provider Demographics
NPI:1508866542
Name:VISWANATHAN, SUBHASH R (MD)
Entity Type:Individual
Prefix:
First Name:SUBHASH
Middle Name:R
Last Name:VISWANATHAN
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 1:555 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2134
Mailing Address - Country:US
Mailing Address - Phone:516-597-5070
Mailing Address - Fax:516-597-5067
Practice Address - Street 1:555 N BROADWAY
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2134
Practice Address - Country:US
Practice Address - Phone:516-597-5070
Practice Address - Fax:516-597-5067
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07825900207P00000X
NY248884207P00000X
CAC149731207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0053783Medicaid
NJ087476Medicare PIN
H03342Medicare UPIN
NJ087476WJ8Medicare PIN