Healthcare Provider Details

I. General information

NPI: 1689611329
Provider Name (Legal Business Name): JAYARAM D PRASAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2788 BAYARD ST SUITE 201
EAST POINT GA
30344-3441
US

IV. Provider business mailing address

2788 BAYARD ST SUITE 201
EAST POINT GA
30344-3441
US

V. Phone/Fax

Practice location:
  • Phone: 404-768-3043
  • Fax: 404-768-1781
Mailing address:
  • Phone: 404-768-3043
  • Fax: 404-768-1781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number035320
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: