Basic Information
| Provider Information | |||||||||
| NPI: | 1750566394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISHNAMOORTHY | ||||||||
| FirstName: | JAYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PONNUSAMY | ||||||||
| OtherFirstName: | JAYASANKARI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1412 MAY ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177022450 | ||||||||
| FaxNumber: | 8177028445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 W ARKANSAS LN | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760136308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177021100 | ||||||||
| FaxNumber: | 8177024801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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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 | 207R00000X | 036119470 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | N0373 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8BQ002 | 01 | TX | BCBS | OTHER | 194635203 | 05 | TX | MEDICAID | P00919161 | 01 | TX | RAILROAD MEDICARE | OTHER | 194635201 | 05 | TX | MEDICAID | 8EB685 | 01 | TX | BCBS | OTHER |