Provider Demographics
NPI:1245294958
Name:ADHIYAMAN, GOMATHI (MD)
Entity type:Individual
Prefix:DR
First Name:GOMATHI
Middle Name:
Last Name:ADHIYAMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GOMATHI
Other - Middle Name:
Other - Last Name:GANESAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MBBS,DGO
Mailing Address - Street 1:7 WOODCREST CT
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1435
Mailing Address - Country:US
Mailing Address - Phone:201-529-8303
Mailing Address - Fax:
Practice Address - Street 1:101 PROSPECT AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1911
Practice Address - Country:US
Practice Address - Phone:201-487-5018
Practice Address - Fax:201-487-5020
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07768600208000000X
NY233282-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics