Provider Demographics
NPI:1659415834
Name:SRINIVASAN, MCDONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:MCDONALD
Middle Name:
Last Name:SRINIVASAN
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 1:43 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-1013
Mailing Address - Country:US
Mailing Address - Phone:201-767-3971
Mailing Address - Fax:201-768-0498
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-894-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03287400207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ309371Medicare ID - Type Unspecified
NJ#CO8176Medicare UPIN