Basic Information
| Provider Information | |||||||||
| NPI: | 1417978677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADHAKRISHNAN | ||||||||
| FirstName: | PUTHENMADAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 PRINCETON PIKE | ||||||||
| Address2: | BLDG 5 SUITE 208 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098157829 | ||||||||
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| Practice Location | |||||||||
| Address1: | 416 BELLEVUE AVE | ||||||||
| Address2: | STE 207 | ||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086184513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099899801 | ||||||||
| FaxNumber: | 6099899806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MA054930 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2247804 | 05 | NJ | MEDICAID |