Provider Demographics
NPI:1841201282
Name:VINAYAGASUNDARAM, BHANUMATHY (MD)
Entity Type:Individual
Prefix:DR
First Name:BHANUMATHY
Middle Name:
Last Name:VINAYAGASUNDARAM
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 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:640 HAWKINS AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779
Practice Address - Country:US
Practice Address - Phone:631-737-0100
Practice Address - Fax:631-471-1117
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02879927Medicaid
NY02879927Medicaid
NY4620PMW661Medicare PIN
NYI65023Medicare UPIN