Healthcare Provider Details

I. General information

NPI: 1407885692
Provider Name (Legal Business Name): VINAITHEERTHA PERUMAL JEYABARATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 S HEALTHPARK DR STE 320
FORT MYERS FL
33908-3630
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-6350
  • Fax: 239-343-4738
Mailing address:
  • Phone: 239-343-6350
  • Fax: 239-343-4738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME82878
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: