Provider Demographics
NPI:1770680688
Name:SETHURAMAN, KINJAL (MD,)
Entity type:Individual
Prefix:
First Name:KINJAL
Middle Name:
Last Name:SETHURAMAN
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:DR
Other - First Name:KINJAL
Other - Middle Name:ASHWIN
Other - Last Name:NANAVATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:PO BOX 64793
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4793
Mailing Address - Country:US
Mailing Address - Phone:410-328-6704
Mailing Address - Fax:410-328-4124
Practice Address - Street 1:22 SOUTH GREENE STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6704
Practice Address - Fax:410-328-4124
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8987207P00000X
NY236222207P00000X
MDD68457207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190262903Medicaid
MD0136OtherBLUE CROSS
TX8AH276OtherBCBSTX
NY02688939Medicaid
TX190262905Medicaid
MD039882900Medicaid
TX613474Medicare PIN
TX190262903Medicaid
TX190262905Medicaid
NY1588Q1Medicare PIN
TX8F8132Medicare PIN