Provider Demographics
NPI:1295870830
Name:PAUL D JAYACHANDRA M D P A
Entity type:Organization
Organization Name:PAUL D JAYACHANDRA M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:FAIRCLOTH
Authorized Official - Suffix:
Authorized Official - Credentials:L P N
Authorized Official - Phone:904-824-7476
Mailing Address - Street 1:1680 OSCEOLA ELEMENTARY SCHOOL ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084
Mailing Address - Country:US
Mailing Address - Phone:904-824-7476
Mailing Address - Fax:904-824-7870
Practice Address - Street 1:1680 OSCEOLA ELEMENTARY SCHOOL ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084
Practice Address - Country:US
Practice Address - Phone:904-824-7476
Practice Address - Fax:904-824-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26220OtherBCBS FLORIDA
FL26220YOtherMEDICARE PROVIDER NUMBER
FL5777008OtherAETNA
FL94163841OtherWAUSA BENIFITS
FLAA919OtherMEDICARE PTAN
FL206068OtherAVMED
FL376531801Medicaid
FL390006717OtherRAILROAD MEDICARE
FL110132302OtherUNITED HEALTHCARE
FL26220YOtherMEDICARE PTAN NUMBER
FL150095OtherWELLCARE
FL150095OtherHEALTHEASE
FL376531800Medicaid
FL26220YOtherMEDICARE PTAN NUMBER
FL150095OtherHEALTHEASE
FL26220AMedicare ID - Type Unspecified