MEDICARE: SMIJA JAYAPRAKASH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	A125663	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AI25663	OTHER	CA	CALIFORNIA LICENSE

General Provider Information

NPI Number	:	1710290648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SMIJA JAYAPRAKASH MD

Provider Business Mailing Address
First Line	:	2460 CANYON LAKES DRIVE
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94582
Country	:	US
Telephone Number	:	408-329-0505
Fax Number	:

Provider Business Practice Location Address
First Line	:	7210 MURRAY DRIVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95201
Country	:	US
Telephone Number	:	209-373-2800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2010
Last Update Date	:	10/29/2015

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