Healthcare Provider Details

I. General information

NPI: 1639133879
Provider Name (Legal Business Name): CARDIOVASCULAR THORACIC ASSOCIATES OF LAKE COUNTY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 FIR ST SUITE 210
EAST CHICAGO IN
46312-3052
US

IV. Provider business mailing address

9201 CALUMET AVE
MUNSTER IN
46321-2807
US

V. Phone/Fax

Practice location:
  • Phone: 219-228-4776
  • Fax:
Mailing address:
  • Phone: 219-836-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID JAYAKAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 219-836-2022