Provider Demographics
NPI:1922425446
Name:JAYANTHAN, PREM (DO)
Entity Type:Individual
Prefix:
First Name:PREM
Middle Name:
Last Name:JAYANTHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12210 PLUM ORCHARD DR STE 212
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-7913
Mailing Address - Country:US
Mailing Address - Phone:301-622-6020
Mailing Address - Fax:301-680-9335
Practice Address - Street 1:12210 PLUM ORCHARD DR STE 212
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904
Practice Address - Country:US
Practice Address - Phone:301-622-6020
Practice Address - Fax:301-680-9335
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0083581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
52-0979135OtherTAX I.D.