Basic Information
| Provider Information | |||||||||
| NPI: | 1790746683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JERE | ||||||||
| FirstName: | SUJATA | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 CEDAR BEND DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787585378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014026 | ||||||||
| FaxNumber: | 5129013867 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 CEDAR BEND DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787585378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014026 | ||||||||
| FaxNumber: | 5129013867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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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 | L3697 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00463326 | 01 | TX | RRMDCR | OTHER | 178189001 | 05 | TX | MEDICAID |