Provider Demographics
NPI:1609012285
Name:IDURY, JAYANTHI
Entity Type:Individual
Prefix:DR
First Name:JAYANTHI
Middle Name:
Last Name:IDURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 DALE RD
Mailing Address - Street 2:KAISER PERMANENETE
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9718
Mailing Address - Country:US
Mailing Address - Phone:925-577-1489
Mailing Address - Fax:
Practice Address - Street 1:4601 DALE RD
Practice Address - Street 2:KAISER PERMANENTE
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9718
Practice Address - Country:US
Practice Address - Phone:925-577-1489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-02
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA106098208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program