Healthcare Provider Details

I. General information

NPI: 1073504577
Provider Name (Legal Business Name): MAHESH PADMANABHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HOBART ST
UTICA NY
13501-4308
US

IV. Provider business mailing address

120 HOBART ST
UTICA NY
13501-4308
US

V. Phone/Fax

Practice location:
  • Phone: 315-798-1149
  • Fax: 315-734-3565
Mailing address:
  • Phone: 315-798-1149
  • Fax: 315-734-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number237715-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: