Provider Demographics
NPI:1427074186
Name:MAHAPATRA, JYOTI S (MD)
Entity type:Individual
Prefix:
First Name:JYOTI
Middle Name:S
Last Name:MAHAPATRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:11111 S 84TH ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-4122
Practice Address - Country:US
Practice Address - Phone:402-593-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23692207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100249951-00Medicaid
NEP00374033OtherRAILROAD MEDICARE
IA0722868Medicaid
NE39-02306OtherSHAREADVANTAGE
NE35611OtherBCBS
NE280681Medicare PIN
NEI67124Medicare UPIN