Healthcare Provider Details

I. General information

NPI: 1083316814
Provider Name (Legal Business Name): JYOTSHAL GHIMIRE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4160
US

IV. Provider business mailing address

1610 DELOS MARR AVE
CHESTERTON IN
46304-4504
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7001
  • Fax:
Mailing address:
  • Phone: 219-902-4538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02008928A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: