Provider Demographics
NPI:1386604049
Name:SRIVATSAN, JAYARAM (MD)
Entity type:Individual
Prefix:DR
First Name:JAYARAM
Middle Name:
Last Name:SRIVATSAN
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 1:8152 N 9TH ST APT 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2274
Mailing Address - Country:US
Mailing Address - Phone:719-251-9403
Mailing Address - Fax:
Practice Address - Street 1:7300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2942
Practice Address - Country:US
Practice Address - Phone:559-448-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-44038207L00000X
CAA112190207LP3000X, 207L00000X
MDD0076331207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0076331OtherMARYLAND LICENSE
NY53601777Medicaid
NYA400001785OtherEMPIRE MEDICARE
CO54988250Medicaid
COI57626Medicare UPIN
C303243Medicare PIN
NYI57626Medicare UPIN
MDD0076331OtherMARYLAND LICENSE
CO44651OtherCOLO LICENSE
MDD0076331OtherMARYLAND LICENSE