Provider Demographics
NPI:1043364839
Name:JOTWANI, VIJAY M (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:M
Last Name:JOTWANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 TIMMONS LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-5926
Mailing Address - Country:US
Mailing Address - Phone:713-441-9000
Mailing Address - Fax:
Practice Address - Street 1:3100 TIMMONS LN
Practice Address - Street 2:SUITE 120
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-5926
Practice Address - Country:US
Practice Address - Phone:713-441-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046265207Q00000X
IN01068588A207Q00000X, 207QS0010X
TXP2270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX331367801Medicaid
TXP01510480OtherRR MEDICARE
TXP01110846OtherRR MEDICARE
TX331367802Medicaid
TX8DH104OtherBLUE CROSS BLUE SHIELD
TX8DY923OtherBLUE CROSS BLUE SHIELD
TX331367802Medicaid
TXP01510480OtherRR MEDICARE
TXP01110846OtherRR MEDICARE
TXTXB157239Medicare PIN