Basic Information
Provider Information | |||||||||
NPI: | 1841226354 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAYANTHI | ||||||||
FirstName: | LATA | ||||||||
MiddleName: | RAO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 80 PHOENIX AVE 201 | ||||||||
Address2: |   | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067021418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037568021 | ||||||||
FaxNumber: | 2035969038 | ||||||||
Practice Location | |||||||||
Address1: | 95 SCOVILL ST | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067061113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037096000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 03/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 031026 | CT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 3140536/4383729 | 01 | CT | AETNA | OTHER | 001310268 | 05 | CT |   | MEDICAID | 010031026CT01 | 01 | CT | ANTHEM BCBS CT | OTHER | 09-21728 | 01 | CT | AMERICHOICE | OTHER | 310260-N063 | 01 | CT | CONNECTICARE | OTHER |