Provider Demographics
NPI:1003279126
Name:KINARIWALA, JAY
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:KINARIWALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 W OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2624
Mailing Address - Country:US
Mailing Address - Phone:313-966-1389
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-1389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2022-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA890752084A2900X
PAMD4710232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103785450Medicaid