Provider Demographics
NPI:1528029568
Name:BATHANI, JAYANTILAL J (MD)
Entity Type:Individual
Prefix:
First Name:JAYANTILAL
Middle Name:J
Last Name:BATHANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:J
Other - Last Name:BATHANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:505 HAZEN ST
Mailing Address - Street 2:STE 203
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079
Mailing Address - Country:US
Mailing Address - Phone:269-657-5545
Mailing Address - Fax:269-657-8776
Practice Address - Street 1:505 HAZEN ST
Practice Address - Street 2:STE 203
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079
Practice Address - Country:US
Practice Address - Phone:269-657-5545
Practice Address - Fax:269-657-8776
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010384352080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC08063570353Medicare ID - Type Unspecified
B46459Medicare UPIN