Provider Demographics
NPI:1629781349
Name:ANANDAN, KARTHIK
Entity Type:Individual
Prefix:
First Name:KARTHIK
Middle Name:
Last Name:ANANDAN
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 1:1133 BOGGIO DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4973
Mailing Address - Country:US
Mailing Address - Phone:505-906-1033
Mailing Address - Fax:
Practice Address - Street 1:2915 W HISTORIC HWY 66 HOWARD JOHNSON HOTEL
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-8730
Practice Address - Country:US
Practice Address - Phone:505-906-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)