Provider Demographics
NPI:1457607400
Name:JETHWA, KRUNAL (MD)
Entity Type:Individual
Prefix:DR
First Name:KRUNAL
Middle Name:
Last Name:JETHWA
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 1:4800 OLDE TOWNE PKWY STE 150A
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4357
Mailing Address - Country:US
Mailing Address - Phone:770-509-1025
Mailing Address - Fax:770-509-1884
Practice Address - Street 1:4800 OLDE TOWNE PKWY STE 150A
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4357
Practice Address - Country:US
Practice Address - Phone:770-509-1025
Practice Address - Fax:770-509-1884
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39401207Q00000X
390200000X
GA87558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC394013Medicaid
SCSC91676121OtherMEDICARE PIN
SCSC91675193OtherMEDICARE PIN
SCSC9167J577OtherMEDICARE PIN
SCSC91676067OtherMEDICARE PIN