Provider Demographics
NPI:1447218342
Name:JAYARAM, PRATHIMA K (MBBS)
Entity Type:Individual
Prefix:
First Name:PRATHIMA
Middle Name:K
Last Name:JAYARAM
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CARTER ST
Mailing Address - Street 2:ATTN: KELLY STEELE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2604
Mailing Address - Country:US
Mailing Address - Phone:585-339-4793
Mailing Address - Fax:585-336-4845
Practice Address - Street 1:1850 BRIGHTON HENRIETTA TOWN LINE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2532
Practice Address - Country:US
Practice Address - Phone:585-424-6210
Practice Address - Fax:585-424-1202
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY179749BJOtherPREFERRED CARE
NY00027433601OtherUNIVERA
NY0414038OtherIHA #
NYP010238530OtherBLUE CHOICE
NY238530-0WOtherWORKERS COMP
NY0414038OtherIHA #