Provider Demographics
NPI:1346580495
Name:JAYASANKER, M R (MD)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:R
Last Name:JAYASANKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:505 N LAKE SHORE DR
Mailing Address - Street 2:1112
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3427
Mailing Address - Country:US
Mailing Address - Phone:312-804-2146
Mailing Address - Fax:312-804-2146
Practice Address - Street 1:505 N LAKE SHORE DR
Practice Address - Street 2:1112
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3427
Practice Address - Country:US
Practice Address - Phone:312-804-2146
Practice Address - Fax:312-804-2146
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036 045002208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery