Provider Demographics
NPI:1831646009
Name:TIMOTHY G JAYASUNDERA MD PC
Entity Type:Organization
Organization Name:TIMOTHY G JAYASUNDERA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-763-6666
Mailing Address - Street 1:PO BOX 287125
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-0019
Mailing Address - Country:US
Mailing Address - Phone:917-214-0084
Mailing Address - Fax:917-536-9945
Practice Address - Street 1:5402 FLATLANDS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2436
Practice Address - Country:US
Practice Address - Phone:718-763-6666
Practice Address - Fax:718-251-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215825-1207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF51932Medicare UPIN