Healthcare Provider Details

I. General information

NPI: 1265685895
Provider Name (Legal Business Name): JESSY R PALAMATTAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N VAN DIEN AVE
RIDGEWOOD NJ
07450-2726
US

IV. Provider business mailing address

223 N VAN DIEN AVE
RIDGEWOOD NJ
07450-2726
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-8000
  • Fax: 201-447-8491
Mailing address:
  • Phone: 201-447-8000
  • Fax: 201-447-8491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA09117100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number264320
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM7500
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: