Provider Demographics
NPI:1407096233
Name:ELIKKOTTIL, JASEENA (MD)
Entity type:Individual
Prefix:
First Name:JASEENA
Middle Name:
Last Name:ELIKKOTTIL
Suffix:
Gender:F
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:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-953-4798
Practice Address - Street 1:4805 SOUTHSIDE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-2111
Practice Address - Country:US
Practice Address - Phone:502-772-8860
Practice Address - Fax:502-996-8309
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49109208M00000X, 207R00000X
246RH0600X
MN22544390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No246RH0600XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyHistology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100437200Medicaid
IN201407600Medicaid