Provider Demographics
NPI:1255331302
Name:INDARAM, JAYASRI (MD)
Entity Type:Individual
Prefix:
First Name:JAYASRI
Middle Name:
Last Name:INDARAM
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 1:10 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1323
Mailing Address - Country:US
Mailing Address - Phone:516-655-3327
Mailing Address - Fax:516-801-2070
Practice Address - Street 1:9709 101ST AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-2523
Practice Address - Country:US
Practice Address - Phone:718-641-5555
Practice Address - Fax:718-641-6677
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193883207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01528252Medicaid
NYF74315Medicare UPIN
NY01528252Medicaid