Provider Demographics
NPI:1679622567
Name:JETHVA, ALPESH R (MD)
Entity Type:Individual
Prefix:
First Name:ALPESH
Middle Name:R
Last Name:JETHVA
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 1:1133 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2130
Mailing Address - Country:US
Mailing Address - Phone:903-595-5486
Mailing Address - Fax:903-595-5128
Practice Address - Street 1:1133 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2130
Practice Address - Country:US
Practice Address - Phone:903-595-5486
Practice Address - Fax:903-595-5128
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK33599207RN0300X
TXK7442207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
390007539OtherRAILROAD MEDICARE
TX143653701Medicaid
OK200214940 AMedicaid
OK200214940 AMedicaid
H34466Medicare UPIN