Healthcare Provider Details

I. General information

NPI: 1376521443
Provider Name (Legal Business Name): NISHITH KISHOR JOBANPUTRA DO, MPH, MTM&H
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DISCOVERY DR PV DEPT, BLDG 45, RM 238
SWIFTWATER PA
18370-9100
US

IV. Provider business mailing address

2908 BROADWAY RD
EASTON PA
18040-7279
US

V. Phone/Fax

Practice location:
  • Phone: 570-895-3138
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number0102201123
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: