=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912942558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARMINI JAYAMAHA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 11/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 632 ROANOKE AVENUE EAST END NEPHROLOGY, P.C.
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-208-8270
-----------------------------------------------------
Fax | 631-208-8271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 MANOR PL SUITE 102
-----------------------------------------------------
City | GREENPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11944-1261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-477-1755
-----------------------------------------------------
Fax | 631-477-1754
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 212805
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------