Provider Demographics
NPI:1912963497
Name:LEA, JAYANTHI SIVASOTHY (MD)
Entity Type:Individual
Prefix:
First Name:JAYANTHI
Middle Name:SIVASOTHY
Last Name:LEA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAYANTHI
Other - Middle Name:
Other - Last Name:SIVASOTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-3838
Mailing Address - Fax:214-645-3839
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-3838
Practice Address - Fax:214-645-3839
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9833207VX0201X, 207V00000X
NC2008-00694207VX0201X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2008-00694OtherSTATE LICENSE
TX165917901Medicaid
SCN94008OtherSC MEDICAID
SCN94008OtherSC MEDICAID
TX8B9714Medicare ID - Type Unspecified
NC2022782Medicare PIN