Basic Information
| Provider Information | |||||||||
| NPI: | 1073504577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PADMANABHAN | ||||||||
| FirstName: | MAHESH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 HOBART ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135014308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157981149 | ||||||||
| FaxNumber: | 3157343565 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 HOBART ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135014308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157981149 | ||||||||
| FaxNumber: | 3157343565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 237715-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02721451 | 05 | NY | MEDICAID |