Provider Demographics
NPI:1316111651
Name:JAYANTHAN.M.D.,P.A
Entity type:Organization
Organization Name:JAYANTHAN.M.D.,P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIRMALADEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYANTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-932-4954
Mailing Address - Street 1:3328 OLD WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3204
Mailing Address - Country:US
Mailing Address - Phone:301-932-4954
Mailing Address - Fax:301-932-5095
Practice Address - Street 1:3328 OLD WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3204
Practice Address - Country:US
Practice Address - Phone:301-932-4954
Practice Address - Fax:301-932-5095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45737207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400866900Medicaid
MD400866900Medicaid