Provider Demographics
NPI:1932152899
Name:BHARATHAN, THAYYULLATHIL (MD)
Entity Type:Individual
Prefix:
First Name:THAYYULLATHIL
Middle Name:
Last Name:BHARATHAN
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 5450
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5450
Mailing Address - Country:US
Mailing Address - Phone:718-246-8600
Mailing Address - Fax:718-246-8601
Practice Address - Street 1:263 7TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-246-8600
Practice Address - Fax:718-246-8601
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114985207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00210908Medicaid
B13270Medicare UPIN
NY00210908Medicaid