Healthcare Provider Details

I. General information

NPI: 1023112034
Provider Name (Legal Business Name): KANTHIMATHI JEGATHESAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2271 EAST MAIN STREET
WATERBURY CT
06705
US

IV. Provider business mailing address

2271 EAST MAIN STREET
WATERBURY CT
06705
US

V. Phone/Fax

Practice location:
  • Phone: 203-753-4131
  • Fax: 203-753-6887
Mailing address:
  • Phone: 203-753-4131
  • Fax: 203-753-6887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number026217
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: