Basic Information
| Provider Information | |||||||||
| NPI: | 1730164526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAYACHANDRAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | VIJAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 MISTLETOE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
| FaxNumber: | 8173359871 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 MISTLETOE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173381300 | ||||||||
| FaxNumber: | 8173359871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | L6078 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | L6078 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 01594798 | 05 | TX | MEDICAID |