Healthcare Provider Details

I. General information

NPI: 1003112657
Provider Name (Legal Business Name): VIJAY KIRAN JAYANTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST STE NW3300
DAYTON OH
45409-2939
US

IV. Provider business mailing address

1300 ANNE ST NW
BEMIDJI MN
56601-5103
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-8394
  • Fax: 937-641-2780
Mailing address:
  • Phone: 218-333-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57.018214
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number108161
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: