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 1:35 PILCHER ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6307
Mailing Address - Country:US
Mailing Address - Phone:347-322-9267
Mailing Address - Fax:
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program