Provider Demographics
NPI:1205171709
Name:JAJU, AMRUTA SURENDRA
Entity type:Individual
Prefix:
First Name:AMRUTA
Middle Name:SURENDRA
Last Name:JAJU
Suffix:
Gender:F
Credentials:
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-2930
Mailing Address - Fax:704-316-2938
Practice Address - Street 1:15825 BALLANTYNE MEDICAL PL STE 220
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4790
Practice Address - Country:US
Practice Address - Phone:704-316-2930
Practice Address - Fax:704-316-2938
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-00750207RE0101X
ZZI DO NOT HAVE207R00000X
OH35.143402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136462OtherLICENSE