Provider Demographics
NPI:1639197288
Name:JEGASOTHY, SHEVANTI MANJULA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHEVANTI
Middle Name:MANJULA
Last Name:JEGASOTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 SAN LORENZO AVE STE 870
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1879
Mailing Address - Country:US
Mailing Address - Phone:305-569-0067
Mailing Address - Fax:305-569-0110
Practice Address - Street 1:135 SAN LORENZO AVE STE 870
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1879
Practice Address - Country:US
Practice Address - Phone:305-569-0067
Practice Address - Fax:305-569-0110
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071046174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255140300Medicaid
FL2292815OtherAETNA
FL2292815OtherAETNA
FL255140300Medicaid