Provider Demographics
NPI:1619996535
Name:MAITRA, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:MAITRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3400 N DYSART RD
Mailing Address - Street 2:UNIT G-127
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-1003
Mailing Address - Country:US
Mailing Address - Phone:623-882-0077
Mailing Address - Fax:623-882-9977
Practice Address - Street 1:3400 N DYSART RD
Practice Address - Street 2:UNIT G-127
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-1003
Practice Address - Country:US
Practice Address - Phone:623-882-0077
Practice Address - Fax:623-882-9977
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ31741207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH74364Medicare UPIN