Provider Demographics
NPI:1639753049
Name:JASWAL, ANITESH (MD)
Entity type:Individual
Prefix:MR
First Name:ANITESH
Middle Name:
Last Name:JASWAL
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 1:494 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2871
Mailing Address - Country:US
Mailing Address - Phone:321-267-8311
Mailing Address - Fax:
Practice Address - Street 1:494 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2871
Practice Address - Country:US
Practice Address - Phone:321-267-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD483220207Q00000X
PAMT224038207Q00000X
390200000X
FLME166386207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program