Provider Demographics
NPI:1407317159
Name:JETTY, KIRTHI KAVYA (DO)
Entity Type:Individual
Prefix:
First Name:KIRTHI
Middle Name:KAVYA
Last Name:JETTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45123-9780
Mailing Address - Country:US
Mailing Address - Phone:937-981-9444
Mailing Address - Fax:
Practice Address - Street 1:1075 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:OH
Practice Address - Zip Code:45123-9780
Practice Address - Country:US
Practice Address - Phone:937-981-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.015685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine