Provider Demographics
NPI:1417448994
Name:RAJAGOPALAN, JAYA SHREE
Entity type:Individual
Prefix:
First Name:JAYA
Middle Name:SHREE
Last Name:RAJAGOPALAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12520 MAGNOLIA BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2355
Mailing Address - Country:US
Mailing Address - Phone:818-452-9902
Mailing Address - Fax:818-452-9882
Practice Address - Street 1:12520 MAGNOLIA BLVD STE 304
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2355
Practice Address - Country:US
Practice Address - Phone:818-452-9902
Practice Address - Fax:818-452-9882
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3107213E00000X
CA5771213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty