Healthcare Provider Details

I. General information

NPI: 1518109420
Provider Name (Legal Business Name): GHAYATHRI JEYAKUMAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GHAYA JEYAKUMAR MD

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4623 160TH ST BASEMENT
FLUSHING NY
11358-3632
US

IV. Provider business mailing address

1093 HICKORY HILL DR
ROCHESTER HILLS MI
48309-1703
US

V. Phone/Fax

Practice location:
  • Phone: 310-357-9793
  • Fax:
Mailing address:
  • Phone: 310-357-9793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA149541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: