Healthcare Provider Details

I. General information

NPI: 1568212876
Provider Name (Legal Business Name): VIKRAM VISHWANATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 04/12/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 N COUNTRY RD MATHER HOSPITAL RADIOLOGY READING ROOM
PORT JEFFERSON NY
11777
US

IV. Provider business mailing address

75 N COUNTRY RD MATHER HOSPITAL RADIOLOGY READING ROOM
PORT JEFFERSON NY
11777
US

V. Phone/Fax

Practice location:
  • Phone: 516-710-8870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number341302
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: