Provider Demographics
NPI:1558358796
Name:KESHA, JYOTHI BHANU (MD)
Entity Type:Individual
Prefix:MRS
First Name:JYOTHI
Middle Name:BHANU
Last Name:KESHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:JYOTHI
Other - Middle Name:
Other - Last Name:BHANU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 240N
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1052
Mailing Address - Country:US
Mailing Address - Phone:651-999-6909
Mailing Address - Fax:651-297-6115
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:SUITE 240
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:763-783-8582
Practice Address - Fax:763-783-8616
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42668208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN307127800Medicaid
MNH22027Medicare UPIN
MN340000645Medicare ID - Type Unspecified