Provider Demographics
NPI:1083717268
Name:GHATNEKAR, JAI V (MD)
Entity Type:Individual
Prefix:
First Name:JAI
Middle Name:V
Last Name:GHATNEKAR
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:PO BOX 2019
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92286-2019
Mailing Address - Country:US
Mailing Address - Phone:760-362-3777
Mailing Address - Fax:760-228-2151
Practice Address - Street 1:6601 WHITE FEATHER RD
Practice Address - Street 2:STE A4
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-6607
Practice Address - Country:US
Practice Address - Phone:760-366-6128
Practice Address - Fax:760-366-6130
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052298208600000X
CAC42883208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200890130Medicaid
CADO365AOtherMEDICARE PROVIDER NUMBER
CADO365AOtherMEDICARE PROVIDER NUMBER