Provider Demographics
NPI:1609862747
Name:JATHAVEDAM, ASHWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHWIN
Middle Name:
Last Name:JATHAVEDAM
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 1:25 ROCKWOOD PLACE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 ROCKWOOD PLACE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-568-3335
Practice Address - Fax:201-568-2450
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237222207R00000X
NJ25MA07857000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I44930Medicare UPIN