Provider Demographics
NPI:1144293473
Name:RAMAKRISHNAN, THEKKEMADOM (MD)
Entity type:Individual
Prefix:
First Name:THEKKEMADOM
Middle Name:
Last Name:RAMAKRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 WILLIAM PENN HWY
Mailing Address - Street 2:SUITE # 303
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-5283
Mailing Address - Country:US
Mailing Address - Phone:610-559-9622
Mailing Address - Fax:
Practice Address - Street 1:2925 WILLIAM PENN HIGHWAY
Practice Address - Street 2:SUITE # 303
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045
Practice Address - Country:US
Practice Address - Phone:610-559-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041515L207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA608831OtherHIGHMARK BLUE SHIELD
PA0012228270002Medicaid
01964701OtherCAPITAL BLUE CROSS OF PA
E55599Medicare UPIN
01964701OtherCAPITAL BLUE CROSS OF PA
PA0012228270002Medicaid