Provider Demographics
NPI:1811908205
Name:JAYASUNDERA, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:JAYASUNDERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2607
Mailing Address - Country:US
Mailing Address - Phone:212-679-4488
Mailing Address - Fax:212-684-4841
Practice Address - Street 1:148 E 38TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2607
Practice Address - Country:US
Practice Address - Phone:212-679-4488
Practice Address - Fax:212-684-4841
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-060847-L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
F51932Medicare UPIN