Provider Demographics
NPI:1285722736
Name:GANESAN, AZHAGASUNDARAM (MD)
Entity type:Individual
Prefix:
First Name:AZHAGASUNDARAM
Middle Name:
Last Name:GANESAN
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 1:534 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-3230
Mailing Address - Country:US
Mailing Address - Phone:976-365-1330
Mailing Address - Fax:973-365-2410
Practice Address - Street 1:534 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3230
Practice Address - Country:US
Practice Address - Phone:976-365-1330
Practice Address - Fax:973-365-2410
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ30225207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2419301Medicaid
NJC55888Medicare UPIN
NJ45237Medicare ID - Type Unspecified