=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740297399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISHNA P JETTI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 02/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12279 ROUTE 30 STE 200
-----------------------------------------------------
City | NORTH HUNTINGDON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15642-1849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-864-4470
-----------------------------------------------------
Fax | 724-863-7120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12279 ROUTE 30 STE 200
-----------------------------------------------------
City | NORTH HUNTINGDON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15642-1849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-864-4470
-----------------------------------------------------
Fax | 724-863-7120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD038024L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------