Provider Demographics
NPI:1518528603
Name:ARIVAZHAGAN, PRADEEPA (MD)
Entity type:Individual
Prefix:
First Name:PRADEEPA
Middle Name:
Last Name:ARIVAZHAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 40TH ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-3919
Mailing Address - Country:US
Mailing Address - Phone:609-647-6038
Mailing Address - Fax:
Practice Address - Street 1:6995 QUEENS MIDTOWN EXPY
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1922
Practice Address - Country:US
Practice Address - Phone:609-647-6038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP100907208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP100907OtherUNIVERSITY OF THE STATE OF NEW YORK, THE STATE EDUCATION DEPARTMENT