Provider Demographics
NPI:1861660029
Name:V P JEYABARATH MD PA
Entity Type:Organization
Organization Name:V P JEYABARATH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:VINAITHEERTHA
Authorized Official - Middle Name:P
Authorized Official - Last Name:JEYABARATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-754-0500
Mailing Address - Street 1:PO BOX 12399
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34603-2399
Mailing Address - Country:US
Mailing Address - Phone:352-754-0500
Mailing Address - Fax:352-754-0515
Practice Address - Street 1:17222 HOSPITAL BLVD
Practice Address - Street 2:STE 116
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8925
Practice Address - Country:US
Practice Address - Phone:352-754-0500
Practice Address - Fax:352-754-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDO2252OtherRAILROAD MCR
FL267210300Medicaid
FLAJ282Medicare PIN