Provider Demographics
NPI:1679252340
Name:GHETIA, JAYKUMAR CHANDRAKANT (MD)
Entity Type:Individual
Prefix:
First Name:JAYKUMAR
Middle Name:CHANDRAKANT
Last Name:GHETIA
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 1:1626 N FIG AVE APT 218
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1400
Mailing Address - Country:US
Mailing Address - Phone:715-502-2005
Mailing Address - Fax:
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5702
Practice Address - Country:US
Practice Address - Phone:715-387-5251
Practice Address - Fax:715-389-4746
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100036-851390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program