Provider Demographics
NPI:1487174512
Name:SWAMINATHAN, SANTOSH
Entity type:Individual
Prefix:
First Name:SANTOSH
Middle Name:
Last Name:SWAMINATHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 HAMDEN AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-2796
Mailing Address - Country:US
Mailing Address - Phone:203-805-2357
Mailing Address - Fax:
Practice Address - Street 1:160 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3808
Practice Address - Country:US
Practice Address - Phone:203-805-2357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC91329208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC913293Medicaid