Provider Demographics
NPI:1588668545
Name:JETHMALANI, SANJEEV (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEV
Middle Name:
Last Name:JETHMALANI
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 1:911 LIGONIER ST
Mailing Address - Street 2:STE 204
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-1805
Mailing Address - Country:US
Mailing Address - Phone:724-537-2210
Mailing Address - Fax:724-537-2545
Practice Address - Street 1:911 LIGONIER ST
Practice Address - Street 2:STE 204
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1805
Practice Address - Country:US
Practice Address - Phone:724-537-2210
Practice Address - Fax:724-537-2545
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045240E207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
F58970Medicare UPIN
707123Medicare ID - Type Unspecified