Basic Information
| Provider Information | |||||||||
| NPI: | 1467523225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GNANARATNEM | ||||||||
| FirstName: | JEEVARATHI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEEVARATNAM | ||||||||
| OtherFirstName: | JEEVARATHI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8555 AERO DRIVE, SUITE 104 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583847828 | ||||||||
| FaxNumber: | 8585986344 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 HEALTH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589394185 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 12/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A61624 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | A61624 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A616240 | 05 | CA | MEDICAID |