Provider Demographics
NPI:1134542855
Name:JEFFERSON PEDIATRICS, PC
Entity type:Organization
Organization Name:JEFFERSON PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GIRIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VEERULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-436-7722
Mailing Address - Street 1:3919 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6811
Mailing Address - Country:US
Mailing Address - Phone:260-436-7722
Mailing Address - Fax:
Practice Address - Street 1:3919 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6811
Practice Address - Country:US
Practice Address - Phone:260-436-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004759A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty