Basic Information
| Provider Information | |||||||||
| NPI: | 1427074186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHAPATRA | ||||||||
| FirstName: | JYOTI | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 11111 S 84TH ST | ||||||||
| Address2: | |||||||||
| City: | PAPILLION | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680464122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025933550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 23692 | NE | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100249951-00 | 05 | NE | MEDICAID | P00374033 | 01 | NE | RAILROAD MEDICARE | OTHER | 0722868 | 05 | IA | MEDICAID | 39-02306 | 01 | NE | SHAREADVANTAGE | OTHER | 35611 | 01 | NE | BCBS | OTHER |