Provider Demographics
NPI:1720017486
Name:JAYAKAR, GANDAM S (MD)
Entity Type:Individual
Prefix:DR
First Name:GANDAM
Middle Name:S
Last Name:JAYAKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25900 GREENFIELD RD STE 140
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1267
Mailing Address - Country:US
Mailing Address - Phone:248-965-3269
Mailing Address - Fax:248-965-2203
Practice Address - Street 1:25900 GREENFIELD RD STE 140
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1267
Practice Address - Country:US
Practice Address - Phone:248-965-3269
Practice Address - Fax:248-965-2203
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGJ036095208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIGJ036095OtherLICENCE NUMBER
MI1938191Medicaid
MI382209691OtherEMPLOYER ID
MI0205009181OtherBLUE CROSS BLUE SHIELD
MI1938191Medicaid
MI382209691OtherEMPLOYER ID