Provider Demographics
NPI:1598878910
Name:THEIVANAYAGAM, KALYANI (MD)
Entity Type:Individual
Prefix:
First Name:KALYANI
Middle Name:
Last Name:THEIVANAYAGAM
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 1:276 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-1437
Mailing Address - Country:US
Mailing Address - Phone:973-669-8181
Mailing Address - Fax:973-669-1687
Practice Address - Street 1:276 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-1437
Practice Address - Country:US
Practice Address - Phone:973-669-8181
Practice Address - Fax:973-669-1687
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06857500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7878109Medicaid
NJ028678 NDYMedicare ID - Type Unspecified
NJ7878109Medicaid