Healthcare Provider Details

I. General information

NPI: 1760836050
Provider Name (Legal Business Name): VYBHAV JETTY MD, MHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 10/29/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BOULDERS PARKWAY SUITE 110
RICHMOND VA
23225
US

IV. Provider business mailing address

1001 BOULDERS PARKWAY SUITE 110
RICHMOND VA
23225
US

V. Phone/Fax

Practice location:
  • Phone: 804-410-9749
  • Fax:
Mailing address:
  • Phone: 804-410-9749
  • Fax: 804-272-3409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number0101282860
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: