Provider Demographics
NPI:1275685638
Name:VIDHUN, JAYAKUMAR RAVICHANDRAN (MD)
Entity Type:Individual
Prefix:
First Name:JAYAKUMAR
Middle Name:RAVICHANDRAN
Last Name:VIDHUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 511
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90608-0511
Mailing Address - Country:US
Mailing Address - Phone:562-698-8141
Mailing Address - Fax:562-698-9885
Practice Address - Street 1:12462 PUTNAM ST.
Practice Address - Street 2:SUITE 506
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1002
Practice Address - Country:US
Practice Address - Phone:562-698-8141
Practice Address - Fax:562-698-9885
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92267207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A922670Medicaid
CAWA92267AMedicare PIN
CAI49687Medicare UPIN
I49687Medicare UPIN