Provider Demographics
NPI:1225059249
Name:JAIKISHEN, JAY PANNATHPUR (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:PANNATHPUR
Last Name:JAIKISHEN
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 1:155 HOSPITAL DR STE 406
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2852
Mailing Address - Country:US
Mailing Address - Phone:337-232-1171
Mailing Address - Fax:
Practice Address - Street 1:155 HOSPITAL DR STE 406
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-232-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08029R207RC0000X, 207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1923907Medicaid
5L358Medicare ID - Type Unspecified
LA1923907Medicaid