Provider Demographics
NPI:1679658835
Name:JAYADEVA, JAY BASAPPA (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:BASAPPA
Last Name:JAYADEVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BASAPPA
Other - Middle Name:
Other - Last Name:JAYADEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-1312
Mailing Address - Country:US
Mailing Address - Phone:607-324-1372
Mailing Address - Fax:585-384-9269
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1025
Practice Address - Country:US
Practice Address - Phone:585-786-8940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143968207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B74994Medicare UPIN