Healthcare Provider Details

I. General information

NPI: 1841226354
Provider Name (Legal Business Name): LATA RAO JAYANTHI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 SCOVILL ST 3RD FLOOR
WATERBURY CT
06706-1113
US

IV. Provider business mailing address

80 PHOENIX AVE 201
WATERBURY CT
06702-1418
US

V. Phone/Fax

Practice location:
  • Phone: 203-709-6000
  • Fax:
Mailing address:
  • Phone: 203-756-8021
  • Fax: 203-596-9038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number031026
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: