MEDICARE: DR. RAJIV JETLY 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	207RI0200X	Infectious Disease Physician	29064	AZ
2	207R00000X	Internal Medicine Physician	29064	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	AZ0887390	OTHER	AZ	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1861494247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAJIV JETLY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1629
Second Line	:	SUITE A
City	:	PRESCOTT
State	:	AZ
Zip	:	86302-1629
Country	:	US
Telephone Number	:	928-772-3340
Fax Number	:	928-759-9611

Provider Business Practice Location Address
First Line	:	3235 N WINDSONG DR
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-1222
Country	:	US
Telephone Number	:	928-772-3340
Fax Number	:	928-759-9611

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	05/11/2017

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Directions to “ DR. RAJIV JETLY M.D.” Practice Location

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