Provider Demographics
NPI:1679575054
Name:JANI, KETAN (MD)
Entity type:Individual
Prefix:DR
First Name:KETAN
Middle Name:
Last Name:JANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47729
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-7729
Mailing Address - Country:US
Mailing Address - Phone:623-934-5600
Mailing Address - Fax:623-934-5603
Practice Address - Street 1:3777 CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7121
Practice Address - Country:US
Practice Address - Phone:928-771-9693
Practice Address - Fax:928-708-0505
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30908207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00063201OtherMEDICARE RAILROAD CARRIER
AZ764606Medicaid
AZZ74221Medicare PIN
AZP00063201OtherMEDICARE RAILROAD CARRIER