Basic Information
| Provider Information | |||||||||
| NPI: | 1609957372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEELER | ||||||||
| FirstName: | JAYANTHI | ||||||||
| MiddleName: | EMMANUEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EMMANUEL | ||||||||
| OtherFirstName: | JAYANTHI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037402503 | ||||||||
| FaxNumber: | 6037402497 | ||||||||
| Practice Location | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037402503 | ||||||||
| FaxNumber: | 6037402497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 12364 | NH | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | P00428678 | 01 | NH | RR MEDICARE | OTHER | 1609957372 | 05 | ME | MEDICAID | 3075403 | 05 | NH | MEDICAID |