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General NPI Number Information
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NPI Number | 1457445033
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Entity Type | Individual
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Provider Name | REVATHI SHANMUGHAM M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/20/2018
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Provider Practice Location Address
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Address Line | 40 EISENHOVER DRIVE
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City | PARAMUS
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State | NJ
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Zip | 07652
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Country | US
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Telephone | 352-686-2972
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Fax |
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Provider Business Mailing Address
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Address Line | 123 ABBIE CT 40 EISENHOWER DRIVE
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City | PARAMUS
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State | NJ
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Zip | 07652
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Country | US
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Telephone | 352-238-5670
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 25MA08398000
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License Number State | NJ
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