Healthcare Provider Details

I. General information

NPI: 1639639974
Provider Name (Legal Business Name): RISHABH GROVER JETHANANDANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKDALE PLZ
BROOKLYN NY
11212-3139
US

IV. Provider business mailing address

450 CLARKSON AVE
BROOKLYN NY
11203-2012
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-6784
  • Fax:
Mailing address:
  • Phone: 718-270-2179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number0101286857
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: