Basic Information
Provider Information | |||||||||
NPI: | 1780201566 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEYAPAULRAJ | ||||||||
FirstName: | JESVIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | THE WRIGHT CENTER FOR GME | ||||||||
Address2: | 501 SOUTH WASHINGTON AVENUE, SUITE 1000 | ||||||||
City: | SCRANTON | ||||||||
State: | PA | ||||||||
PostalCode: | 18505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705915153 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | THE WRIGHT CENTER FOR GME | ||||||||
Address2: | 501 SOUTH WASHINGTON AVENUE, SUITE 1000 | ||||||||
City: | SCRANTON | ||||||||
State: | PA | ||||||||
PostalCode: | 18505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705915153 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2020 | ||||||||
LastUpdateDate: | 07/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 01/17/2022 | ||||||||
NPIReactivationDate: | 07/11/2022 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.