Provider Demographics
NPI:1629758107
Name:JAITLY, MANSI
Entity Type:Individual
Prefix:
First Name:MANSI
Middle Name:
Last Name:JAITLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 SPRING STREET
Mailing Address - Street 2:EAST 6TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013
Mailing Address - Country:US
Mailing Address - Phone:866-283-7122
Mailing Address - Fax:
Practice Address - Street 1:1911 4TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-1984
Practice Address - Country:US
Practice Address - Phone:510-584-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist