Basic Information
| Provider Information | |||||||||
| NPI: | 1396839346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHENDIRAN | ||||||||
| FirstName: | GAJAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S. SERVICE RD. | ||||||||
| Address2: | STE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453107 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WARRENTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201863027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403490514 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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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 | 207LP2900X | 0101237547 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 139698 | 01 | VA | ANTHEM | OTHER | 9396107 | 01 | VA | PHCS | OTHER | K142-0001 | 01 | VA | CARE FIRST 2005 | OTHER | 484645 | 01 | VA | NCPPO | OTHER | 296032 | 01 | VA | AMERIGROUP | OTHER | 1396839346 | 05 | VA | MEDICAID |