Basic Information
| Provider Information | |||||||||
| NPI: | 1649409400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEYARAJ | ||||||||
| FirstName: | VANITHA | ||||||||
| MiddleName: | ISAAC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | VANITHA | ||||||||
| OtherMiddleName: | ISAAC | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 SOUTH STATE STREET | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 320 WEST COMMERCE RD | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483811892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486847337 | ||||||||
| FaxNumber: | 2486841286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 4301104104 | MI | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | 125-056436 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.