Provider Demographics
NPI:1659682904
Name:JESUBATHAM, JULIAN JERROD (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIAN
Middle Name:JERROD
Last Name:JESUBATHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542-3432
Mailing Address - Country:US
Mailing Address - Phone:251-968-7379
Mailing Address - Fax:251-968-5960
Practice Address - Street 1:200 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-3432
Practice Address - Country:US
Practice Address - Phone:251-968-7379
Practice Address - Fax:251-968-5960
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.36071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL244212Medicaid