Provider Demographics
NPI:1295793263
Name:KALANADHABHATTA, VIVEKANAND (MD)
Entity type:Individual
Prefix:DR
First Name:VIVEKANAND
Middle Name:
Last Name:KALANADHABHATTA
Suffix:
Gender:M
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:PO BOX 1050
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-0322
Mailing Address - Country:US
Mailing Address - Phone:516-761-7636
Mailing Address - Fax:718-756-0545
Practice Address - Street 1:443 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2821
Practice Address - Country:US
Practice Address - Phone:718-736-3591
Practice Address - Fax:845-252-9935
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182717207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01468051Medicaid
NM01468051Medicaid