Provider Demographics
NPI:1902190648
Name:ANANTHAKRISHNAN, NITYA (MD)
Entity Type:Individual
Prefix:DR
First Name:NITYA
Middle Name:
Last Name:ANANTHAKRISHNAN
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 1:4 FORT WASHINGTON PL
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4843
Mailing Address - Country:US
Mailing Address - Phone:201-926-6490
Mailing Address - Fax:
Practice Address - Street 1:14 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3003
Practice Address - Country:US
Practice Address - Phone:508-473-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-29
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10039696390200000X
MA257926208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program