Provider Demographics
NPI:1629174297
Name:JAYAGOPAL, SALEM G (MD,)
Entity Type:Individual
Prefix:DR
First Name:SALEM
Middle Name:G
Last Name:JAYAGOPAL
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BENGEYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:EAST WILLISTON
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1931
Mailing Address - Country:US
Mailing Address - Phone:516-873-9031
Mailing Address - Fax:
Practice Address - Street 1:600 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2604
Practice Address - Country:US
Practice Address - Phone:718-920-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154058207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00782545Medicaid
NY04D281Medicare ID - Type Unspecified
NY00782545Medicaid