Provider Demographics
NPI:1740297399
Name:JETTI, KRISHNA P (MD)
Entity type:Individual
Prefix:MR
First Name:KRISHNA
Middle Name:P
Last Name:JETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12279 ROUTE 30
Mailing Address - Street 2:STE 200
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642-1849
Mailing Address - Country:US
Mailing Address - Phone:724-864-4470
Mailing Address - Fax:724-863-7120
Practice Address - Street 1:12279 ROUTE 30
Practice Address - Street 2:STE 200
Practice Address - City:NORTH HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:15642-1849
Practice Address - Country:US
Practice Address - Phone:724-864-4470
Practice Address - Fax:724-863-7120
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD038024L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAJE55077OtherBS
PA100159OtherUPNCE
PA0009633780001Medicaid
PA0009633780001Medicaid