Healthcare Provider Details

I. General information

NPI: 1245294958
Provider Name (Legal Business Name): GOMATHI ADHIYAMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GOMATHI GANESAN M.B.B.S.,D.G.O.

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PROSPECT AVE SUITE 1C
HACKENSACK NJ
07601-1911
US

IV. Provider business mailing address

7 WOODCREST CT
MAHWAH NJ
07430-1435
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-5018
  • Fax: 201-487-5020
Mailing address:
  • Phone: 201-529-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07768600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number233282-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: