Provider Demographics
NPI:1669764627
Name:GOSALAKKAL, JAYAPRAKASH AYILLATH (MD)
Entity type:Individual
Prefix:DR
First Name:JAYAPRAKASH
Middle Name:AYILLATH
Last Name:GOSALAKKAL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7633 E JEFFERSON AVE
Mailing Address - Street 2:STE 270
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214
Mailing Address - Country:US
Mailing Address - Phone:313-499-1282
Mailing Address - Fax:313-499-1324
Practice Address - Street 1:7633 E JEFFERSON AVE
Practice Address - Street 2:STE 270
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214
Practice Address - Country:US
Practice Address - Phone:313-499-1282
Practice Address - Fax:313-499-1324
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2019-01-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35-098366208000000X, 2084N0402X
CAA 74084208000000X, 2084N0402X
MI4301104329208VP0000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35-098366OtherMEDICAL LICENSURE