MEDICARE: NIREN JASUTKAR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	LP01844	RI
2	207RG0100X	Gastroenterology Physician	25MA09962100	NJ

General Provider Information

NPI Number	:	1134447493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIREN JASUTKAR M.D.

Provider Business Mailing Address
First Line	:	219 N BROAD ST FL 5
Second Line	:	DIVISION OF GASTROENTEROLOGY
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-1507
Country	:	US
Telephone Number	:	215-762-6072
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 MAYWOOD AVE
Second Line	:
City	:	MAYWOOD
State	:	NJ
Zip	:	07607-1001
Country	:	US
Telephone Number	:	551-257-7005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2010
Last Update Date	:	04/18/2019

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