Provider Demographics
NPI:1780663112
Name:KORIVI, JYOTHIRMAYEE (M D)
Entity Type:Individual
Prefix:
First Name:JYOTHIRMAYEE
Middle Name:
Last Name:KORIVI
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2018
Mailing Address - Country:US
Mailing Address - Phone:860-450-7471
Mailing Address - Fax:
Practice Address - Street 1:330 WASHINGTON ST
Practice Address - Street 2:SUITE 510
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2700
Practice Address - Country:US
Practice Address - Phone:860-885-1308
Practice Address - Fax:860-889-1982
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008010675Medicaid
CTI26624Medicare UPIN
CTA400088427Medicare PIN