Provider Demographics
NPI:1548293079
Name:DALSANIA, JIVAN (MD)
Entity type:Individual
Prefix:DR
First Name:JIVAN
Middle Name:
Last Name:DALSANIA
Suffix:
Gender:M
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:PO BOX 171181
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-1181
Mailing Address - Country:US
Mailing Address - Phone:901-682-2872
Mailing Address - Fax:
Practice Address - Street 1:1068 CRESTHAVEN RD
Practice Address - Street 2:SUITE 150
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0800
Practice Address - Country:US
Practice Address - Phone:901-682-6828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17381207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050049460OtherRR MEDICARE
MS00019608OtherMISSISSIPPI MEDICAID
TN3029532Medicaid
TN3018829OtherBLUE CROSS
050049460OtherRR MEDICARE
TN3029532Medicaid
050049460OtherRR MEDICARE
TNC46953Medicare UPIN
TN3029532Medicare PIN
TN3029532Medicaid