Basic Information
| Provider Information | |||||||||
| NPI: | 1396853529 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RAO | ||||||||
| FirstName: | JAYANTH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 3RD AVE | ||||||||
| Address2: | MANAGED CARE DEPARTMENT | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112203702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307124 | ||||||||
| FaxNumber: | 7186307437 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 55TH ST | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112202559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186307415 | ||||||||
| FaxNumber: | 7186307437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 154022 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00773322 | 05 | NY | MEDICAID |