Basic Information
| Provider Information | |||||||||
| NPI: | 1629015037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INDARAM | ||||||||
| FirstName: | ANANT | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | INDARAM | ||||||||
| OtherFirstName: | ANANT | ||||||||
| OtherMiddleName: | V | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10 CARRIAGE DR | ||||||||
| Address2: | |||||||||
| City: | OLD WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115681323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163587210 | ||||||||
| FaxNumber: | 5163522596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 HILLSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110402521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163587210 | ||||||||
| FaxNumber: | 5163522596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 191398 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.