Provider Demographics
NPI:1215122452
Name:JAY G. WANI, M.D., INC.
Entity type:Organization
Organization Name:JAY G. WANI, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-525-3113
Mailing Address - Street 1:1401 SPANOS CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2810
Mailing Address - Country:US
Mailing Address - Phone:209-525-3113
Mailing Address - Fax:209-525-3114
Practice Address - Street 1:1401 SPANOS CT
Practice Address - Street 2:SUITE 102
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2810
Practice Address - Country:US
Practice Address - Phone:209-525-3113
Practice Address - Fax:209-525-3114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8726716Medicaid
CA8726716Medicaid
CAA26756Medicare UPIN