Healthcare Provider Details

I. General information

NPI: 1538298963
Provider Name (Legal Business Name): JAYARAJU PASMATHOOR RAJU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAYARAJU PASMATHOOR RAJU M.D

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 06/20/2021
Certification Date: 06/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NOYES ST
UTICA NY
13502-3854
US

IV. Provider business mailing address

115 JUBILEE LN
NEW HARTFORD NY
13413-4401
US

V. Phone/Fax

Practice location:
  • Phone: 315-738-4405
  • Fax:
Mailing address:
  • Phone: 315-790-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number238041
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier238041
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerMEDICAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: