1538192703 NPI number — DR. SATHYA G JYOTHINAGARAM M.D.,

Table of content: DR. SATHYA G JYOTHINAGARAM M.D., (NPI 1538192703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538192703 NPI number — DR. SATHYA G JYOTHINAGARAM M.D.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JYOTHINAGARAM
Provider First Name:
SATHYA
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.,
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538192703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
925 E MCDOWELL RD FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85006-2502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-839-5895
Provider Business Mailing Address Fax Number:
602-839-0589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 E MCDOWELL RD FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85006-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-839-5895
Provider Business Practice Location Address Fax Number:
602-839-0589
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  58662 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X , with the licence number: 48182 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110240775 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8947697 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47697 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5901374 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: N00863 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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