Healthcare Provider Details

I. General information

NPI: 1366505372
Provider Name (Legal Business Name): JANARDHANA MAHADEVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 MAIN STREET
DELHI NY
13753
US

IV. Provider business mailing address

174 MAIN STREET
DELHI NY
13753
US

V. Phone/Fax

Practice location:
  • Phone: 607-746-6467
  • Fax: 607-746-6465
Mailing address:
  • Phone: 607-746-6467
  • Fax: 607-746-6465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number121637
License Number StateNY

VIII. Authorized Official

Name: JANARDHANA MAHADEVA
Title or Position: PRESIDENT
Credential: MD
Phone: 607-746-6467