Healthcare Provider Details

I. General information

NPI: 1386745867
Provider Name (Legal Business Name): VELLORE PADMANABAN JAYAKRISHNAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 OVINGTON AVE SUITE 203
BROOKLYN NY
11209-1459
US

IV. Provider business mailing address

355 OVINGTON AVE SUITE 203
BROOKLYN NY
11209-1459
US

V. Phone/Fax

Practice location:
  • Phone: 718-748-4871
  • Fax: 718-833-3940
Mailing address:
  • Phone: 718-748-4871
  • Fax: 718-833-3940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number128925
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: