Healthcare Provider Details

I. General information

NPI: 1740493501
Provider Name (Legal Business Name): LATHA M. JAYARAMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 KUMHO DR SUITE NUMBER 202
FAIRLAWN OH
44333-9297
US

IV. Provider business mailing address

822 KUMHO DR SUITE NUMBER 202
FAIRLAWN OH
44333-9297
US

V. Phone/Fax

Practice location:
  • Phone: 330-576-0500
  • Fax: 330-576-0467
Mailing address:
  • Phone: 330-576-0500
  • Fax: 330-576-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.092072
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.092072
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: