NPIMap

Organization Active NPI

Jefferson Park Pediatrics P C

  • Pediatrics Physician
  • Fort Wayne, IN
National Provider Identifier
1629263181
Registry record updated Apr 23, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
JEFFERSON PARK PEDIATRICS P C
Practice address
3919 W Jefferson Blvd Ste 1
Fort Wayne, IN 46804-6811
Phone
(260) 436-7722
Fax
(260) 459-0012
NPI assigned
Sep 7, 2007
Last updated
Apr 23, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 23, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Giridhar Rao Veerula, MDNPI 1154421303
Title
Owner
Phone
(260) 436-7722

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 174400000X
Integrative Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 202D00000X
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

3919 W Jefferson Blvd Ste 1
Fort Wayne, IN 46804-6811

Mailing address

3919 W Jefferson Blvd Ste 1
Fort Wayne, IN 46804-6811
Phone (260) 436-7722

Other practice location 1

3919 W Jefferson Blvd Ste 2
Fort Wayne, IN 46804-6811
Phone (260) 450-1313

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190114000442 IN Part B Supplier - Clinic/Group Practice 2961748991 Receives reassigned benefits from 8 practitioners
Practice locations: Fort Wayne, IN

National Provider Directory

National Provider Directory

Locations

3919 W Jefferson Blvd
#1
Fort Wayne, IN 46804

950 W North St
Kendallville, IN 46755

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1189123200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1745366400000",
    "number": "1629263181",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3919 W JEFFERSON BLVD STE 1",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468046811",
            "telephone_number": "260-436-7722",
            "fax_number": "260-459-0012"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3919 W JEFFERSON BLVD STE 1",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468046811",
            "telephone_number": "260-436-7722",
            "fax_number": "260-459-0012"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3919 W Jefferson Blvd Ste 2",
            "address_purpose": "LOCATION",
            "city": "Fort Wayne",
            "state": "IN",
            "postal_code": "468046811",
            "country_code": "US",
            "telephone_number": "260-450-1313",
            "fax_number": "260-436-7722",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "JEFFERSON PARK PEDIATRICS P C",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-07",
        "last_updated": "2025-04-23",
        "certification_date": "2025-04-23",
        "status": "A",
        "authorized_official_last_name": "VEERULA",
        "authorized_official_first_name": "GIRIDHAR",
        "authorized_official_middle_name": "RAO",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "260-436-7722",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "202D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Integrative Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 23, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.