Provider Demographics
NPI:1710465810
Name:NIRTHANANTHAN, NIRUBAN
Entity Type:Individual
Prefix:
First Name:NIRUBAN
Middle Name:
Last Name:NIRTHANANTHAN
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 1:407 CINCINNATI ST
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:LA
Mailing Address - Zip Code:71232-3007
Mailing Address - Country:US
Mailing Address - Phone:318-878-3737
Mailing Address - Fax:318-878-6420
Practice Address - Street 1:407 CINCINNATI ST
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:LA
Practice Address - Zip Code:71232-3007
Practice Address - Country:US
Practice Address - Phone:318-878-3737
Practice Address - Fax:318-878-6420
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA329164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program