Provider Demographics
NPI:1841226354
Name:JAYANTHI, LATA RAO (MD)
Entity type:Individual
Prefix:
First Name:LATA
Middle Name:RAO
Last Name:JAYANTHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PHOENIX AVE 201
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1418
Mailing Address - Country:US
Mailing Address - Phone:203-756-8021
Mailing Address - Fax:203-596-9038
Practice Address - Street 1:95 SCOVILL ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1113
Practice Address - Country:US
Practice Address - Phone:203-709-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031026208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3140536/4383729OtherAETNA
CT001310268Medicaid
CT010031026CT01OtherANTHEM BCBS CT
CT09-21728OtherAMERICHOICE
CT310260-N063OtherCONNECTICARE
CT001310268Medicaid
CT370001482Medicare PIN