Provider Demographics
NPI:1629015037
Name:INDARAM, ANANT V (MD)
Entity Type:Individual
Prefix:DR
First Name:ANANT
Middle Name:V
Last Name:INDARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ANANT
Other - Middle Name:V
Other - Last Name:INDARAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1323
Mailing Address - Country:US
Mailing Address - Phone:516-358-7210
Mailing Address - Fax:516-352-2596
Practice Address - Street 1:1575 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2521
Practice Address - Country:US
Practice Address - Phone:516-358-7210
Practice Address - Fax:516-352-2596
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191398207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF50205Medicare UPIN
NYG300000136Medicare PIN