Healthcare Provider Details

I. General information

NPI: 1245216605
Provider Name (Legal Business Name): JAYRAM KRISHNAN D.O., M.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 ROUTE 73
VOORHEES NJ
08043-9598
US

IV. Provider business mailing address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 877-388-2778
  • Fax: 856-424-7529
Mailing address:
  • Phone: 908-273-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MB08869800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: