Provider Demographics
NPI:1538463799
Name:RANGADHAMA, JYOTHI H (MD)
Entity Type:Individual
Prefix:
First Name:JYOTHI
Middle Name:H
Last Name:RANGADHAMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JYOTHI
Other - Middle Name:B
Other - Last Name:CHETIYAAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:155 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4057
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:845-703-6297
Practice Address - Street 1:81 RONALD REAGAN BLVD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-4105
Practice Address - Country:US
Practice Address - Phone:845-794-6999
Practice Address - Fax:845-703-6297
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10228300207V00000X
NY267768207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03583539Medicaid
NY03583539Medicaid