Provider Demographics
NPI:1689115867
Name:MOTTA, JISHU KAUL
Entity Type:Individual
Prefix:DR
First Name:JISHU
Middle Name:KAUL
Last Name:MOTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BAYSTATE MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-0001
Mailing Address - Country:US
Mailing Address - Phone:413-794-0000
Mailing Address - Fax:
Practice Address - Street 1:BAYSTATE MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-0001
Practice Address - Country:US
Practice Address - Phone:413-794-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT65607208M00000X
CT65606207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine