Healthcare Provider Details

I. General information

NPI: 1033164363
Provider Name (Legal Business Name): LAVANYA JITENDRANATH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR STREET HARTFORD HOSPITAL DEPT OF MEDICINE INFECTIOUS DISEASES
HARTFORD CT
06102-8000
US

IV. Provider business mailing address

80 S MAIN ST
MIDDLETOWN CT
06457-3648
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6878
  • Fax: 860-358-6412
Mailing address:
  • Phone: 860-358-6878
  • Fax: 860-358-6412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number045367
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: