Provider Demographics
NPI:1003040429
Name:MAHAJAN, NIYATI (MD)
Entity type:Individual
Prefix:
First Name:NIYATI
Middle Name:
Last Name:MAHAJAN
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:366-716-0238
Mailing Address - Fax:
Practice Address - Street 1:2295 E 14TH ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-6804
Practice Address - Country:US
Practice Address - Phone:336-713-8860
Practice Address - Fax:336-713-8862
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.099107208000000X
NC2019-02164208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064908Medicaid