1588120778 NPI number — MS. POOJA MOHAN JETHANI MOT, OTR

Table of content: MS. POOJA MOHAN JETHANI MOT, OTR (NPI 1588120778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588120778 NPI number — MS. POOJA MOHAN JETHANI MOT, OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JETHANI
Provider First Name:
POOJA
Provider Middle Name:
MOHAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MOT, OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588120778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 LINDELL BOULEVARD, APARTMENT A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-254-1696
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4444 FOREST PARK AVENUE, WASHINGTON UNIVERSITY IN ST LO
Provider Second Line Business Practice Location Address:
SUITE NO - 2210, CB 8505
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-286-1669
Provider Business Practice Location Address Fax Number:
314-289-6131
Provider Enumeration Date:
02/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  40141 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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