Provider Demographics
NPI:1821435348
Name:SURUJDYAL, JAYA N (DO)
Entity Type:Individual
Prefix:DR
First Name:JAYA
Middle Name:N
Last Name:SURUJDYAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806
Mailing Address - Country:US
Mailing Address - Phone:321-843-3220
Mailing Address - Fax:321-843-3210
Practice Address - Street 1:83 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806
Practice Address - Country:US
Practice Address - Phone:321-843-3220
Practice Address - Fax:321-843-3210
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14043208000000X
FLUO3552390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS14043OtherMEDICAL LICENSE
FL017877600Medicaid
FL017877600Medicaid