Provider Demographics
NPI:1548464324
Name:RAMANADHAM, SMITA R (MD)
Entity type:Individual
Prefix:
First Name:SMITA
Middle Name:R
Last Name:RAMANADHAM
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 1:2 CORNWALL DRIVE
Mailing Address - Street 2:#B2
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816
Mailing Address - Country:US
Mailing Address - Phone:617-233-9928
Mailing Address - Fax:
Practice Address - Street 1:2 CORNWALL DRIVE
Practice Address - Street 2:UNIT B2
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816
Practice Address - Country:US
Practice Address - Phone:617-233-9928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA260824208600000X, 2086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110101030AMedicaid
BP1-0026542OtherINSTITUTIONAL PERMIT