Provider Demographics
NPI:1760655187
Name:JAYAPRAKASH, MARIONETTE SUJITHA (M D)
Entity Type:Individual
Prefix:
First Name:MARIONETTE
Middle Name:SUJITHA
Last Name:JAYAPRAKASH
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-1332
Mailing Address - Fax:
Practice Address - Street 1:2000 GLENWOOD AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5676
Practice Address - Country:US
Practice Address - Phone:815-741-4445
Practice Address - Fax:815-741-3047
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-01640207R00000X
IL036.128479207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine