Provider Demographics
NPI:1790877835
Name:JANI, JYOTIR (MD)
Entity Type:Individual
Prefix:
First Name:JYOTIR
Middle Name:
Last Name:JANI
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 1:528 PANTHER DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-5400
Mailing Address - Country:US
Mailing Address - Phone:706-387-5656
Mailing Address - Fax:770-623-5674
Practice Address - Street 1:528 PANTHER DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-5400
Practice Address - Country:US
Practice Address - Phone:706-387-5656
Practice Address - Fax:770-623-5674
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA076524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH83713Medicare UPIN
ILP00021374Medicare ID - Type UnspecifiedRR INDIVIDUAL #
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILL98534Medicare ID - Type UnspecifiedINDIVIDUAL #
IL833120Medicare ID - Type UnspecifiedGROUP #