Provider Demographics
NPI:1598907990
Name:SIVANANTHAN, GEETHAN
Entity Type:Individual
Prefix:
First Name:GEETHAN
Middle Name:
Last Name:SIVANANTHAN
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 1:49 HASTINGS RD
Mailing Address - Street 2:
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824-1045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:695 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7200
Practice Address - Country:US
Practice Address - Phone:908-688-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-31
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09696600207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ04670781Medicaid