Basic Information
Provider Information | |||||||||
NPI: | 1417911660 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAYAKAR | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 19036 | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049154085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9032916191 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 707 HOLLYBROOK DR | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | TX | ||||||||
PostalCode: | 756052410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9032916191 | ||||||||
FaxNumber: | 9032916155 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 11/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N6893 | TX | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | N6893 | TX | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 215876802 | 05 | TX |   | MEDICAID |