Provider Demographics
NPI:1548297971
Name:SUBBARAYAN, SRIVIDHYA (MD)
Entity type:Individual
Prefix:
First Name:SRIVIDHYA
Middle Name:
Last Name:SUBBARAYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2524
Mailing Address - Country:US
Mailing Address - Phone:732-494-8442
Mailing Address - Fax:
Practice Address - Street 1:78 HARDING AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-2524
Practice Address - Country:US
Practice Address - Phone:732-494-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07067800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G87271Medicare UPIN