Healthcare Provider Details

I. General information

NPI: 1407007115
Provider Name (Legal Business Name): JAYASRI BUKKAPATNAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W COLUMBIA ST
ORLANDO FL
32806-1133
US

IV. Provider business mailing address

21 W COLUMBIA ST
ORLANDO FL
32806-1133
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5560
  • Fax: 407-425-5947
Mailing address:
  • Phone: 321-841-5560
  • Fax: 407-425-5947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME104383
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: