Provider Demographics
NPI:1649409400
Name:JEYARAJ, VANITHA ISAAC (MD)
Entity Type:Individual
Prefix:DR
First Name:VANITHA
Middle Name:ISAAC
Last Name:JEYARAJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VANITHA
Other - Middle Name:ISAAC
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:320 WEST COMMERCE RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1892
Practice Address - Country:US
Practice Address - Phone:248-684-7337
Practice Address - Fax:248-684-1286
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301104104207W00000X
IL125-056436390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program