Healthcare Provider Details

I. General information

NPI: 1548362486
Provider Name (Legal Business Name): ANITA JEYAKUMAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8423 MARKET ST STE 210
BOARDMAN OH
44512-6778
US

IV. Provider business mailing address

8423 MARKET ST STE 210
BOARDMAN OH
44512-6778
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-1934
  • Fax: 330-729-1861
Mailing address:
  • Phone: 330-729-1934
  • Fax: 330-729-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number35.087978
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35.087978
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: