Provider Demographics
NPI:1710290648
Name:JAYAPRAKASH, SMIJA (MD)
Entity Type:Individual
Prefix:
First Name:SMIJA
Middle Name:
Last Name:JAYAPRAKASH
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 1:2460 CANYON LAKES DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582
Mailing Address - Country:US
Mailing Address - Phone:408-329-0505
Mailing Address - Fax:
Practice Address - Street 1:7210 MURRAY DRIVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95201
Practice Address - Country:US
Practice Address - Phone:209-373-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1256632080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAI25663OtherCALIFORNIA LICENSE