Provider Demographics
NPI:1972615029
Name:SMUCKER, JAYANTHI RACHAKONDA (MD)
Entity type:Individual
Prefix:DR
First Name:JAYANTHI
Middle Name:RACHAKONDA
Last Name:SMUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JAYANTHI
Other - Middle Name:RACHAKONDA
Other - Last Name:SARMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0809
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-533-1234
Practice Address - Street 1:415 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2322
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-533-1234
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360986272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00159341OtherRAILROAD MEDICARE
IL036098627Medicaid
IL540733OtherHEALTHLINK
IL093984OtherHEALTH ALLIANCE
ILP00159341OtherRAILROAD MEDICARE
ILK10208Medicare ID - Type UnspecifiedPROVIDER NUMBER