Provider Demographics
NPI:1912351594
Name:SIVADASAN, MITHUN
Entity type:Individual
Prefix:
First Name:MITHUN
Middle Name:
Last Name:SIVADASAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 STATE ROUTE 35 STE 1
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2038
Mailing Address - Country:US
Mailing Address - Phone:732-790-5599
Mailing Address - Fax:
Practice Address - Street 1:1270 STATE ROUTE 35 STE 1
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2038
Practice Address - Country:US
Practice Address - Phone:732-790-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2024-08-23
Deactivation Date:2024-07-09
Deactivation Code:
Reactivation Date:2024-08-01
Provider Licenses
StateLicense IDTaxonomies
CT1047213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty