1891725081 NPI number — GLAUCOMA PRACTICE OF NEW YORK, PLLC

Table of content: DR. JAYASRI DASAR RAJU MD (NPI 1679748552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891725081 NPI number — GLAUCOMA PRACTICE OF NEW YORK, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLAUCOMA PRACTICE OF NEW YORK, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891725081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-0358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-533-6565
Provider Business Mailing Address Fax Number:
518-533-6567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 NEW SCOTLAND RD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
SLINGERLANDS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12159-9386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-533-6565
Provider Business Practice Location Address Fax Number:
518-533-6567
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GANDHAM
Authorized Official First Name:
SAI
Authorized Official Middle Name:
BHUJANGARAO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
518-533-6565

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DF0279 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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