Provider Demographics
NPI:1750566394
Name:KRISHNAMOORTHY, JAYA (MD)
Entity type:Individual
Prefix:
First Name:JAYA
Middle Name:
Last Name:KRISHNAMOORTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAYASANKARI
Other - Middle Name:
Other - Last Name:PONNUSAMY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1412 MAY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7639
Mailing Address - Country:US
Mailing Address - Phone:817-702-2450
Mailing Address - Fax:817-702-8445
Practice Address - Street 1:1050 W ARKANSAS LN
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-6308
Practice Address - Country:US
Practice Address - Phone:817-702-1100
Practice Address - Fax:817-702-4801
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119470207R00000X
TXN0373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BQ002OtherBCBS
TX194635203Medicaid
TXP00919161OtherRAILROAD MEDICARE
TX194635201Medicaid
TX8EB685OtherBCBS
TX194635203Medicaid
TX8EB685OtherBCBS