Provider Demographics
NPI:1013910652
Name:SUBRAMANIAM-MOOTHATHU, POOVILLAM S (MD, FAAN, FAHA, CIME)
Entity Type:Individual
Prefix:DR
First Name:POOVILLAM
Middle Name:S
Last Name:SUBRAMANIAM-MOOTHATHU
Suffix:
Gender:M
Credentials:MD, FAAN, FAHA, CIME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 WALSING DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-8133
Mailing Address - Country:US
Mailing Address - Phone:804-741-6484
Mailing Address - Fax:
Practice Address - Street 1:3400 BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1418
Practice Address - Country:US
Practice Address - Phone:804-741-6484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010412062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC36491Medicare UPIN