Provider Demographics
NPI:1811905961
Name:NANAVATI, AJAY (MD)
Entity type:Individual
Prefix:
First Name:AJAY
Middle Name:
Last Name:NANAVATI
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 1:275 VARNUM AVE STE 201
Mailing Address - Street 2:RIVERSIDE MEDICAL GROUP
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:978-452-9700
Mailing Address - Fax:978-441-6075
Practice Address - Street 1:275 VARNUM AVE STE 201
Practice Address - Street 2:RIVERSIDE MEDICAL GROUP
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:978-452-9700
Practice Address - Fax:978-441-6075
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12534207R00000X
MA220686207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204715Medicaid
NHI 19991Medicare UPIN
RE 7961Medicare ID - Type Unspecified