Provider Demographics
NPI:1629263181
Name:JEFFERSON PARK PEDIATRICS P C
Entity Type:Organization
Organization Name:JEFFERSON PARK PEDIATRICS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GIRIDHAR
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:VEERULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-7722
Mailing Address - Street 1:3919 W JEFFERSON BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6811
Mailing Address - Country:US
Mailing Address - Phone:260-436-7722
Mailing Address - Fax:260-459-0012
Practice Address - Street 1:3919 W JEFFERSON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6811
Practice Address - Country:US
Practice Address - Phone:260-436-7722
Practice Address - Fax:260-459-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200262620Medicaid