Healthcare Provider Details

I. General information

NPI: 1790465417
Provider Name (Legal Business Name): JASPAUL DHANOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 S MAIN ST
ELKHART IN
46517-3125
US

IV. Provider business mailing address

3421 S MAIN ST
ELKHART IN
46517-3125
US

V. Phone/Fax

Practice location:
  • Phone: 574-295-7178
  • Fax:
Mailing address:
  • Phone: 574-295-7178
  • Fax: 574-295-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01099855A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: