Provider Demographics
NPI:1124778543
Name:KAKUTURU, JYOTHI
Entity type:Individual
Prefix:
First Name:JYOTHI
Middle Name:
Last Name:KAKUTURU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 OLD EMMORTON RD STE 220
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-6189
Mailing Address - Country:US
Mailing Address - Phone:410-569-9040
Mailing Address - Fax:
Practice Address - Street 1:2227 OLD EMMORTON RD STE 220
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-6189
Practice Address - Country:US
Practice Address - Phone:410-569-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDH0104151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program