Provider Demographics
NPI:1306057856
Name:JYOTHINAGARAM, SRIKANTH THYAGARAJ (MD)
Entity type:Individual
Prefix:
First Name:SRIKANTH
Middle Name:THYAGARAJ
Last Name:JYOTHINAGARAM
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 1:1650 W COLLEGE ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3565
Mailing Address - Country:US
Mailing Address - Phone:817-388-3440
Mailing Address - Fax:817-388-3441
Practice Address - Street 1:1650 W COLLEGE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3565
Practice Address - Country:US
Practice Address - Phone:817-388-3440
Practice Address - Fax:817-388-3441
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089867207R00000X, 208M00000X
TXQ2456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5186424Medicaid
MISJ089867OtherMICHIGAN LICENSE
MI1306057856Medicaid
MI700E012740OtherBCBSM GROUP NUMBER
MI700E012740OtherBCBSM GROUP NUMBER
MI5186424Medicaid