Provider Demographics
NPI:1346248135
Name:JASTI, KISHAN KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:KISHAN
Middle Name:KUMAR
Last Name:JASTI
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 1:25195 KELLY ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4909
Mailing Address - Country:US
Mailing Address - Phone:586-775-4594
Mailing Address - Fax:586-775-4506
Practice Address - Street 1:25195 KELLY ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4909
Practice Address - Country:US
Practice Address - Phone:586-775-4594
Practice Address - Fax:586-775-4506
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424918207R00000X
MI4301088186207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011127Medicaid
MI060502617OtherBCBS
PA1013818260002Medicaid
MI1346248135Medicaid
PA093337QJDMedicare PIN
MI1346248135Medicaid
PAI36917Medicare UPIN