Provider Demographics
NPI:1104225713
Name:DASARATHULA, JYOTHSNA (MD)
Entity type:Individual
Prefix:
First Name:JYOTHSNA
Middle Name:
Last Name:DASARATHULA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 W RAHN RD STE 102
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2219
Mailing Address - Country:US
Mailing Address - Phone:937-433-8990
Mailing Address - Fax:937-433-8691
Practice Address - Street 1:33 W RAHN RD STE 102
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2219
Practice Address - Country:US
Practice Address - Phone:937-433-8990
Practice Address - Fax:937-433-8691
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35143732207R00000X
390200000X
IL036143010208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMULTISPECIALTY GROUP PTAN