Healthcare Provider Details

I. General information

NPI: 1245447838
Provider Name (Legal Business Name): JAYASHREE VASA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FORD PL
DETROIT MI
48202-3450
US

IV. Provider business mailing address

C203 KSR GREEN VALLEY SUBSTATION ROAD NEAR R & B GUEST HOUSE, MADHAVADHARA
VISHAKAPATNAM ANDHRA PRADESH
530018
IN

V. Phone/Fax

Practice location:
  • Phone: 313-874-6677
  • Fax:
Mailing address:
  • Phone: 248-293-2830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085953
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01088785A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: