Provider Demographics
NPI:1861504417
Name:DAVE, JAIMINI A (MD)
Entity Type:Individual
Prefix:
First Name:JAIMINI
Middle Name:A
Last Name:DAVE
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:P.O. BOX 629
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-1006
Mailing Address - Country:US
Mailing Address - Phone:770-948-6824
Mailing Address - Fax:770-948-6804
Practice Address - Street 1:3870 MEDICAL PARK DRIVE SUITE 200
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1110
Practice Address - Country:US
Practice Address - Phone:770-948-6824
Practice Address - Fax:770-948-6804
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041103207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF89918Medicare UPIN
GA05BDKSCMedicare ID - Type Unspecified