Basic Information
| Provider Information | |||||||||
| NPI: | 1780663112 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KORIVI | ||||||||
| FirstName: | JYOTHIRMAYEE | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604507471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 WASHINGTON ST | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608851308 | ||||||||
| FaxNumber: | 8608891982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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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 | 207Q00000X | 042476 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008010675 | 05 | CT | MEDICAID |