Healthcare Provider Details

I. General information

NPI: 1679658835
Provider Name (Legal Business Name): JAY BASAPPA JAYADEVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BASAPPA JAYADEVA M.D.

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N MAIN ST
WARSAW NY
14569-1025
US

IV. Provider business mailing address

7 SENECA ST
HORNELL NY
14843-1312
US

V. Phone/Fax

Practice location:
  • Phone: 585-786-8940
  • Fax:
Mailing address:
  • Phone: 607-324-1372
  • Fax: 585-384-9269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number143968
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: