Healthcare Provider Details

I. General information

NPI: 1245467067
Provider Name (Legal Business Name): RAXITKUMAR JINJUVADIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 CLYDE MORRIS BLVD STE 100
PORT ORANGE FL
32129-2349
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 386-788-1242
  • Fax: 386-756-8802
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301093965
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301093965
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME151069
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: