Provider Demographics
NPI:1114934866
Name:AJUDIA, KETAN P (MD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:P
Last Name:AJUDIA
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 45680
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94145-0680
Mailing Address - Country:US
Mailing Address - Phone:530-622-1441
Mailing Address - Fax:
Practice Address - Street 1:1100 MARSHALL WAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6533
Practice Address - Country:US
Practice Address - Phone:530-344-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78074207R00000X, 207RI0008X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI-15296Medicare UPIN
CAI-15296Medicare UPIN