Provider Demographics
NPI:1194156612
Name:JEYAMITRA, DEVARAJ (MD)
Entity type:Individual
Prefix:DR
First Name:DEVARAJ
Middle Name:
Last Name:JEYAMITRA
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 1:22 CHARDONNAY RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1768
Mailing Address - Country:US
Mailing Address - Phone:631-292-2610
Mailing Address - Fax:
Practice Address - Street 1:22 CHARDONNAY RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1768
Practice Address - Country:US
Practice Address - Phone:631-292-2610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122286-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AJ6446404OtherDEA REGISTRATION