Provider Demographics
NPI:1417151911
Name:MITHYANTHA, JAHNAVI (MD)
Entity Type:Individual
Prefix:DR
First Name:JAHNAVI
Middle Name:
Last Name:MITHYANTHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 74
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8481
Mailing Address - Fax:269-341-7781
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 74
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:269-341-7781
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087292207R00000X
KY43420207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417151911Medicaid
MI1417961137OtherBCBSM - BMH
MI1417151911Medicaid