Healthcare Provider Details

I. General information

NPI: 1861494247
Provider Name (Legal Business Name): RAJIV JETLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 N WINDSONG DR
PRESCOTT VALLEY AZ
86314-1222
US

IV. Provider business mailing address

PO BOX 1629 SUITE A
PRESCOTT AZ
86302-1629
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-3340
  • Fax: 928-759-9611
Mailing address:
  • Phone: 928-772-3340
  • Fax: 928-759-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29064
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number29064
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: