Provider Demographics
NPI:1033221486
Name:JAYAWANT, MARK LEE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:JAYAWANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SCENIC DR.
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626
Mailing Address - Country:US
Mailing Address - Phone:512-715-4227
Mailing Address - Fax:
Practice Address - Street 1:1900 SCENIC DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7724
Practice Address - Country:US
Practice Address - Phone:512-715-4227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7303208G00000X
ND13204208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCH81184Medicare UPIN
TX8F24137Medicare PIN