Healthcare Provider Details

I. General information

NPI: 1386879542
Provider Name (Legal Business Name): DEEPAK SRINIVASAN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11-10 5TH ST
FAIR LAWN NJ
07410-1473
US

IV. Provider business mailing address

11-10 5TH ST
FAIR LAWN NJ
07410-1473
US

V. Phone/Fax

Practice location:
  • Phone: 201-312-7682
  • Fax:
Mailing address:
  • Phone: 201-312-7682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMA06740000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMA06740000
License Number StateNJ

VIII. Authorized Official

Name: DEEPAK SRINIVASAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-312-7682