Provider Demographics
NPI:1487992970
Name:RADHAKRISHNAN, SRINIVASAN
Entity type:Individual
Prefix:
First Name:SRINIVASAN
Middle Name:
Last Name:RADHAKRISHNAN
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 1:63 WHITNEY ST
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2432
Mailing Address - Country:US
Mailing Address - Phone:201-767-2424
Mailing Address - Fax:202-784-2354
Practice Address - Street 1:63 WHITNEY ST
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-2432
Practice Address - Country:US
Practice Address - Phone:201-767-2424
Practice Address - Fax:202-784-2354
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011770-1261QP2000X
NY011770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy