Provider Demographics
NPI:1033164363
Name:JITENDRANATH, LAVANYA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAVANYA
Middle Name:
Last Name:JITENDRANATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3648
Mailing Address - Country:US
Mailing Address - Phone:860-358-6878
Mailing Address - Fax:860-358-6412
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL DEPT OF MEDICINE INFECTIOUS DISEASES
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-358-6878
Practice Address - Fax:860-358-6412
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045367207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT440000193OtherMEDICARE PROV #
CT001453670Medicaid