Provider Demographics
NPI:1578679544
Name:JETHWA, KUSUM ANIL (MD)
Entity Type:Individual
Prefix:MRS
First Name:KUSUM
Middle Name:ANIL
Last Name:JETHWA
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 1:117 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208
Mailing Address - Country:US
Mailing Address - Phone:908-354-1400
Mailing Address - Fax:908-354-6235
Practice Address - Street 1:117 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208
Practice Address - Country:US
Practice Address - Phone:908-354-1400
Practice Address - Fax:908-354-1400
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA27756208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1529200Medicaid
NJC55326Medicare UPIN