Provider Demographics
NPI:1790752186
Name:SUBRAMANIAN, JEEVARATHNA (MD)
Entity Type:Individual
Prefix:
First Name:JEEVARATHNA
Middle Name:
Last Name:SUBRAMANIAN
Suffix:
Gender:F
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-2731
Practice Address - Fax:774-442-4672
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA273391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH06988Medicare UPIN
MI0D16184071Medicare ID - Type Unspecified
MI4158327Medicaid
MI1558407189OtherGROUP NPI
MI0D16184071Medicare ID - Type Unspecified