Healthcare Provider Details

I. General information

NPI: 1104269760
Provider Name (Legal Business Name): THANUJA JEYAKUMAR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2013
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5686 BROADVIEW RD APT 2507
PARMA OH
44134-1655
US

IV. Provider business mailing address

5686 BROADVIEW RD APT 2507
PARMA OH
44134-1655
US

V. Phone/Fax

Practice location:
  • Phone: 216-280-0456
  • Fax:
Mailing address:
  • Phone: 216-280-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA10632800
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD61115695
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: