Provider Demographics
NPI:1912968918
Name:KUNDUMADATHIL, JAYADEVAN (MD)
Entity Type:Individual
Prefix:
First Name:JAYADEVAN
Middle Name:
Last Name:KUNDUMADATHIL
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 1:406 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4280
Mailing Address - Country:US
Mailing Address - Phone:321-473-8974
Mailing Address - Fax:321-473-8976
Practice Address - Street 1:406 5TH AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4280
Practice Address - Country:US
Practice Address - Phone:321-473-8974
Practice Address - Fax:321-473-8976
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110205422OtherRAIL ROAD MEDICARE
FL258183300Medicaid
FL49497ZMedicare ID - Type Unspecified
FL258183300Medicaid