Provider Demographics
NPI:1073173738
Name:AMBALAVANAN, JAYACHIDAMBARAM (MD)
Entity type:Individual
Prefix:DR
First Name:JAYACHIDAMBARAM
Middle Name:
Last Name:AMBALAVANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9048
Mailing Address - Country:US
Mailing Address - Phone:207-396-7700
Mailing Address - Fax:207-396-7701
Practice Address - Street 1:175 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9048
Practice Address - Country:US
Practice Address - Phone:207-396-7700
Practice Address - Fax:207-396-7701
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-15
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD27390207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism