Provider Demographics
NPI:1982660783
Name:AJMERI, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:AJMERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JYOTENDRA
Other - Middle Name:
Other - Last Name:AJMERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4723 N TOMNITZ PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-7403
Mailing Address - Country:US
Mailing Address - Phone:520-465-7415
Mailing Address - Fax:
Practice Address - Street 1:4723 N TOMNITZ PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-7403
Practice Address - Country:US
Practice Address - Phone:520-465-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0157190A207R00000X
AZ31832207R00000X
MN102590 TEMP PERMIT207R00000X
MN48811207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138886Medicare PIN
AZH94536Medicare UPIN