Basic Information
| Provider Information | |||||||||
| NPI: | 1437727799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JETTY | ||||||||
| FirstName: | AVNISH | ||||||||
| MiddleName: | SIDHARTH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1761 NW 165TH AVE | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330281712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546091968 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 SW 75TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331552805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052645252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TRN32552 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.