Provider Demographics
NPI:1992794705
Name:MADHUSOODANAN, SUBRAMONIAM (MD)
Entity type:Individual
Prefix:DR
First Name:SUBRAMONIAM
Middle Name:
Last Name:MADHUSOODANAN
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 1:249 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1511
Mailing Address - Country:US
Mailing Address - Phone:516-371-1804
Mailing Address - Fax:516-371-1804
Practice Address - Street 1:327 B 19TH STREET
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:718-869-7375
Practice Address - Fax:718-869-8532
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1389572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00528890Medicaid
40A553OtherEMPIRE BC
B14252Medicare UPIN
02981GMedicare ID - Type UnspecifiedGHI