Provider Demographics
NPI:1023112034
Name:JEGATHESAN, KANTHIMATHI (MD)
Entity type:Individual
Prefix:MRS
First Name:KANTHIMATHI
Middle Name:
Last Name:JEGATHESAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705
Mailing Address - Country:US
Mailing Address - Phone:203-753-4131
Mailing Address - Fax:203-753-6887
Practice Address - Street 1:2271 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705
Practice Address - Country:US
Practice Address - Phone:203-753-4131
Practice Address - Fax:203-753-6887
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001262170Medicaid
CT0R1849OtherHEALTH NET
CT010026217CT01OtherBCBS
CT001262170Medicaid
CT110002906Medicare ID - Type Unspecified