Provider Demographics
NPI:1477790095
Name:JADEGONDANAHALLI, JAI (MD)
Entity Type:Individual
Prefix:DR
First Name:JAI
Middle Name:
Last Name:JADEGONDANAHALLI
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 1:500 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5001
Mailing Address - Country:US
Mailing Address - Phone:432-640-2834
Mailing Address - Fax:432-640-2897
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5001
Practice Address - Country:US
Practice Address - Phone:432-640-2834
Practice Address - Fax:432-640-2897
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN7286207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program