Provider Demographics
NPI:1124216080
Name:JETTY, AMAR CHAND (MD)
Entity Type:Individual
Prefix:
First Name:AMAR
Middle Name:CHAND
Last Name:JETTY
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 1:1100 CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2751
Mailing Address - Country:US
Mailing Address - Phone:719-383-5189
Mailing Address - Fax:719-383-6566
Practice Address - Street 1:1100 CARSON AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2751
Practice Address - Country:US
Practice Address - Phone:719-383-5189
Practice Address - Fax:719-383-6566
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR45869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODR-45869OtherSTATE LICENSE
COP00452978OtherRAILROAD MEDICARE
CO13352857Medicaid
COC811439Medicare PIN