Provider Demographics
NPI:1760664387
Name:S MANJULA JEGASOTHY MD PA
Entity Type:Organization
Organization Name:S MANJULA JEGASOTHY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEVANTI
Authorized Official - Middle Name:MANJULA
Authorized Official - Last Name:JEGASOTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-569-0067
Mailing Address - Street 1:135 SAN LORENZO AVE STE 870
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1879
Mailing Address - Country:US
Mailing Address - Phone:305-569-0067
Mailing Address - Fax:305-569-0110
Practice Address - Street 1:135 SAN LORENZO AVE STE 870
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1879
Practice Address - Country:US
Practice Address - Phone:305-569-0067
Practice Address - Fax:305-569-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG67731Medicare UPIN