Healthcare Provider Details

I. General information

NPI: 1407349145
Provider Name (Legal Business Name): JAINY VATHIKULAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DR STE 100
SAN RAFAEL CA
94903-4151
US

IV. Provider business mailing address

4000 CIVIC CENTER DR STE 100
SAN RAFAEL CA
94903-4151
US

V. Phone/Fax

Practice location:
  • Phone: 628-877-0040
  • Fax:
Mailing address:
  • Phone: 628-877-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number20A17874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: