Provider Demographics
NPI:1043218514
Name:KANDASWAMY JAYARAJ MD PA
Entity Type:Organization
Organization Name:KANDASWAMY JAYARAJ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KANDASWAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-892-2111
Mailing Address - Street 1:PO BOX 12499
Mailing Address - Street 2:3030 N ST #310
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-2499
Mailing Address - Country:US
Mailing Address - Phone:409-892-2111
Mailing Address - Fax:409-892-2173
Practice Address - Street 1:3030 NORTH ST
Practice Address - Street 2:#310
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1433
Practice Address - Country:US
Practice Address - Phone:409-892-2111
Practice Address - Fax:409-892-2173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6963207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00420XMedicare ID - Type Unspecified
G76802Medicare UPIN