Healthcare Provider Details

I. General information

NPI: 1629263181
Provider Name (Legal Business Name): JEFFERSON PARK PEDIATRICS P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3919 W JEFFERSON BLVD STE 1
FORT WAYNE IN
46804-6811
US

IV. Provider business mailing address

3919 W JEFFERSON BLVD STE 1
FORT WAYNE IN
46804-6811
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-7722
  • Fax: 260-459-0012
Mailing address:
  • Phone: 260-436-7722
  • Fax: 260-459-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GIRIDHAR RAO VEERULA
Title or Position: OWNER
Credential: MD
Phone: 260-436-7722