Basic Information
| Provider Information | |||||||||
| NPI: | 1669623351 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHAJAN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 E ADAMS ST # UH4143 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644720 | ||||||||
| FaxNumber: | 3154644905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2008 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 253748 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 253748 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03123888 | 05 | NY | MEDICAID |