Provider Demographics
NPI:1679871180
Name:VENKATESAN, JAYARAMAN (MD)
Entity type:Individual
Prefix:
First Name:JAYARAMAN
Middle Name:
Last Name:VENKATESAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 MILSTEAD AVE NE STE 100
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3877
Mailing Address - Country:US
Mailing Address - Phone:770-483-9330
Mailing Address - Fax:
Practice Address - Street 1:1412 MILSTEAD AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:770-483-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256488207RC0000X, 207RI0011X
GA91781207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVF283AMedicare PIN
VAC10680Medicare PIN