Provider Demographics
NPI:1477923498
Name:OLICKAL, JINY MATHEW (MD)
Entity Type:Individual
Prefix:
First Name:JINY
Middle Name:MATHEW
Last Name:OLICKAL
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 1:1009 W SAINT MAARTENS DR STE F
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2990
Mailing Address - Country:US
Mailing Address - Phone:816-232-8145
Mailing Address - Fax:816-279-1840
Practice Address - Street 1:1009 W SAINT MAARTENS DR STE F
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2990
Practice Address - Country:US
Practice Address - Phone:816-232-8145
Practice Address - Fax:816-279-1840
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN20587207R00000X
MO2018038324207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine