Healthcare Provider Details

I. General information

NPI: 1841466034
Provider Name (Legal Business Name): VIDYA JAYAWARDENA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PKWY
WEST ROXBURY MA
02132-4927
US

IV. Provider business mailing address

1400 VFW PARKWAY # 128 SPINAL CORD INJURY UNIT, VA MEDICAL CENTER
WEST ROXBURY MA
02132
US

V. Phone/Fax

Practice location:
  • Phone: 857-203-6455
  • Fax:
Mailing address:
  • Phone: 857-203-6588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number0101226801
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: