Provider Demographics
NPI:1457629453
Name:JAYAKUMAR THOTAMBILU, PHYSICIAN, P.C.
Entity Type:Organization
Organization Name:JAYAKUMAR THOTAMBILU, PHYSICIAN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYAKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:THOTAMBILU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-592-4000
Mailing Address - Street 1:522 S 4TH ST
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-2946
Mailing Address - Country:US
Mailing Address - Phone:315-592-4001
Mailing Address - Fax:315-593-3222
Practice Address - Street 1:522 S 4TH ST
Practice Address - Street 2:SUITE 1300
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2946
Practice Address - Country:US
Practice Address - Phone:315-592-4000
Practice Address - Fax:315-593-3222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01805352Medicaid
NYG51168Medicare UPIN