Provider Demographics
NPI:1295760049
Name:JAIWATANA, JAISIRI (MD)
Entity type:Individual
Prefix:
First Name:JAISIRI
Middle Name:
Last Name:JAIWATANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E. WOODROW WILSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5199
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-364-1588
Practice Address - Street 1:1500 E. WOODROW WILSON DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-364-1588
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD9250174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist