Provider Demographics
NPI:1467523225
Name:GNANARATNEM, JEEVARATHI (MD)
Entity Type:Individual
Prefix:
First Name:JEEVARATHI
Middle Name:
Last Name:GNANARATNEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEEVARATHI
Other - Middle Name:
Other - Last Name:SEEVARATNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8555 AERO DRIVE, SUITE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-384-7828
Mailing Address - Fax:858-598-6344
Practice Address - Street 1:3003 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2700
Practice Address - Country:US
Practice Address - Phone:858-939-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61624208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A616240Medicaid