Provider Demographics
NPI:1699849620
Name:KRISHNAN, MAHADEVAN G (MD)
Entity type:Individual
Prefix:DR
First Name:MAHADEVAN
Middle Name:G
Last Name:KRISHNAN
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 1:609 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5227
Mailing Address - Country:US
Mailing Address - Phone:732-901-8822
Mailing Address - Fax:732-367-2897
Practice Address - Street 1:609 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5227
Practice Address - Country:US
Practice Address - Phone:732-901-8822
Practice Address - Fax:732-367-2897
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0458542086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ542526Medicare ID - Type Unspecified
NJC60258Medicare UPIN
NJ255389SWBMedicare PIN