Provider Demographics
NPI:1487608725
Name:KETHEESWARAN, MARKANDU (MD)
Entity type:Individual
Prefix:DR
First Name:MARKANDU
Middle Name:
Last Name:KETHEESWARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:KETHEESWARAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1209 CAPE CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4404
Mailing Address - Country:US
Mailing Address - Phone:910-485-7003
Mailing Address - Fax:910-485-7103
Practice Address - Street 1:1209 CAPE CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4404
Practice Address - Country:US
Practice Address - Phone:910-485-7003
Practice Address - Fax:910-485-7103
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701004207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891087EMedicaid
NC01814OtherBLUE CROSS & BLUE SHIELD
NC2244064AMedicare ID - Type Unspecified
NC891087EMedicaid