Provider Demographics
NPI:1669632782
Name:JETHAVA, ASHIF K (MD)
Entity Type:Individual
Prefix:
First Name:ASHIF
Middle Name:K
Last Name:JETHAVA
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 1:671 HIOAKS RD STE B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4072
Mailing Address - Country:US
Mailing Address - Phone:804-272-5814
Mailing Address - Fax:804-560-0232
Practice Address - Street 1:4720 PUDDLEDOCK RD
Practice Address - Street 2:SUITE 100B
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875
Practice Address - Country:US
Practice Address - Phone:508-334-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA262848207R00000X, 390200000X
CT049340207R00000X, 208M00000X
VA0101264655207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1669632782Medicaid
MA110103533/AMedicaid