Provider Demographics
NPI:1932187143
Name:JETHANANDANI, VIJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:
Last Name:JETHANANDANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MBA
Mailing Address - Street 1:582 MARKET ST STE 1608
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-5317
Mailing Address - Country:US
Mailing Address - Phone:415-521-1506
Mailing Address - Fax:877-448-3551
Practice Address - Street 1:582 MARKET ST STE 1608
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-5317
Practice Address - Country:US
Practice Address - Phone:415-521-1506
Practice Address - Fax:877-448-3551
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD196652084P0800X
CA1284802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN26001117OtherRAILROAD MEDICARE
TN1932187143OtherNPI
TN3043268Medicaid
TN4005548OtherBLUE BLUE CROSS
TNB37271Medicare UPIN
TN3043268Medicaid