Provider Demographics
NPI:1821234972
Name:NATHAN, PONNUDURAI (MD)
Entity Type:Individual
Prefix:DR
First Name:PONNUDURAI
Middle Name:
Last Name:NATHAN
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 1:106 YOUR HOST LN
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-4364
Mailing Address - Country:US
Mailing Address - Phone:856-303-0898
Mailing Address - Fax:
Practice Address - Street 1:106 YOUR HOST LN
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-4364
Practice Address - Country:US
Practice Address - Phone:856-303-0898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03696700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3944409Medicaid
NJE60700Medicare UPIN