Provider Demographics
NPI:1124103874
Name:PATTATHIL, JEAN C (MD)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:C
Last Name:PATTATHIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:240 WILLIAMSON ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202
Mailing Address - Country:US
Mailing Address - Phone:908-355-8877
Mailing Address - Fax:908-355-0017
Practice Address - Street 1:240 WILLIAMSON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202
Practice Address - Country:US
Practice Address - Phone:908-355-8877
Practice Address - Fax:908-355-0017
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07295500207R00000X, 302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9065806Medicaid
NJ9065806Medicaid
H73330Medicare UPIN