Provider Demographics
NPI:1306000351
Name:SAH, JITENDRA (MD)
Entity Type:Individual
Prefix:
First Name:JITENDRA
Middle Name:
Last Name:SAH
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-672-6620
Practice Address - Fax:260-672-6639
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092336207R00000X
IN01070764A208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000762679OtherANTHEM
INP01071809OtherR.R. MEDICARE
IN201058600Medicaid
INP01071809OtherR.R. MEDICARE