=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528053162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAYANTH G RAO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2005
-----------------------------------------------------
Last Update Date | 05/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3406 N LECANTO HWY. SUITE A
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34465-3548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-746-1100
-----------------------------------------------------
Fax | 352-422-7023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 COLONIAL BLVD ATTN: PAYER CONTRACTING & RELATIONS
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-931-7342
-----------------------------------------------------
Fax | 239-931-7385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | ME 65465
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------