Healthcare Provider Details

I. General information

NPI: 1669664447
Provider Name (Legal Business Name): JAI P NAIDU IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 PRATT AVE
TOWANDA PA
18848
US

IV. Provider business mailing address

91 HOSPITAL DR
TOWANDA PA
18848-9702
US

V. Phone/Fax

Practice location:
  • Phone: 570-268-2594
  • Fax: 570-265-2328
Mailing address:
  • Phone: 570-268-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD037174L
License Number StatePA

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: