Provider Demographics
NPI:1760836050
Name:JETTY, VYBHAV (MD, MHA)
Entity type:Individual
Prefix:
First Name:VYBHAV
Middle Name:
Last Name:JETTY
Suffix:
Gender:M
Credentials:MD, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BOULDERS PARKWAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:804-410-9749
Mailing Address - Fax:804-272-3409
Practice Address - Street 1:1001 BOULDERS PARKWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225
Practice Address - Country:US
Practice Address - Phone:804-410-9749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101282860207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology