Provider Demographics
NPI:1376282319
Name:JEGANATHAN, JERISAN (DPM)
Entity type:Individual
Prefix:
First Name:JERISAN
Middle Name:
Last Name:JEGANATHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HAMBURG TPKE STE 108
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2033
Mailing Address - Country:US
Mailing Address - Phone:973-925-4111
Mailing Address - Fax:
Practice Address - Street 1:510 HAMBURG TPKE STE 108
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2033
Practice Address - Country:US
Practice Address - Phone:973-925-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MD00388700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program