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: | |
Other - Suffix: | |
Other - Last Name Type: | |
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
State | License ID | Taxonomies |
---|---|---|
MI | GJ036095 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | GJ036095 | Other | LICENCE NUMBER |
MI | 1938191 | Medicaid | |
MI | 382209691 | Other | EMPLOYER ID |
MI | 0205009181 | Other | BLUE CROSS BLUE SHIELD |
MI | 1938191 | Medicaid | |
MI | 382209691 | Other | EMPLOYER ID |