Provider Demographics
NPI:1396736054
Name:AMIN, JITENDRA M (MD)
Entity type:Individual
Prefix:
First Name:JITENDRA
Middle Name:M
Last Name:AMIN
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:PO BOX 245
Mailing Address - Street 2:725 N SPENCER ST
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173
Mailing Address - Country:US
Mailing Address - Phone:765-932-5996
Mailing Address - Fax:765-932-4996
Practice Address - Street 1:725 N SPENCER ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173
Practice Address - Country:US
Practice Address - Phone:765-932-5996
Practice Address - Fax:765-932-4996
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030547A207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100216000AMedicaid
IN710510Medicare ID - Type Unspecified
B29336Medicare UPIN