Healthcare Provider Details

I. General information

NPI: 1255647673
Provider Name (Legal Business Name): JAYA PRAKASH SUGUNARAJ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 THE CROSSROADS BLVD STE A
CARMEL CA
93923-8685
US

IV. Provider business mailing address

100 WILSON RD STE 100
MONTEREY CA
93940-7885
US

V. Phone/Fax

Practice location:
  • Phone: 831-718-9701
  • Fax:
Mailing address:
  • Phone: 831-649-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberC169256
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberC169256
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: