Provider Demographics
NPI:1043521826
Name:RAJU, JAYA (BS)
Entity type:Individual
Prefix:MRS
First Name:JAYA
Middle Name:
Last Name:RAJU
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1394
Mailing Address - Country:US
Mailing Address - Phone:718-967-4692
Mailing Address - Fax:
Practice Address - Street 1:100 KENILWORTH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1394
Practice Address - Country:US
Practice Address - Phone:718-967-4692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004052-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist