Provider Demographics
NPI:1962649426
Name:MUTHU, JOHN S (MBBS; MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:MUTHU
Suffix:
Gender:M
Credentials:MBBS; MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-4436
Mailing Address - Country:US
Mailing Address - Phone:516-750-5432
Mailing Address - Fax:
Practice Address - Street 1:528 PROSPECT PLACE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238
Practice Address - Country:US
Practice Address - Phone:718-613-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003934207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine