Basic Information
| Provider Information | |||||||||
| NPI: | 1528053162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAO | ||||||||
| FirstName: | JAYANTH | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | ATTN: PAYER CONTRACTING & RELATIONS | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 3406 N LECANTO HWY. | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344653548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527461100 | ||||||||
| FaxNumber: | 3524227023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | ME 65465 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 25903 | 01 | FL | BCBS OF FL | OTHER | 103495 | 01 | FL | AVMED | OTHER | 25903 | 01 | FL | BCBS | OTHER | P00056 | 01 | FL | FREEDOM HEALTH | OTHER | P00909691 | 01 | FL | RR MEDICARE | OTHER | P01254190 | 01 | FL | RAILROAD MCR | OTHER | P201226 | 01 | FL | OPTIMUM | OTHER | 2486569 | 01 | FL | CIGNA | OTHER | 5002104 | 01 | FL | AETNA | OTHER | P502641 | 05 | FL | MEDICAID | 346441900 | 05 | FL | MEDICAID | 937635 | 01 | FL | WELLCARE | OTHER |