1093810632 NPI number — DR. SIDDHARTH GULABCHAND JAIN MD

Table of content: MEGAN LEE-ANN MADDOX ACSW (NPI 1366228520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093810632 NPI number — DR. SIDDHARTH GULABCHAND JAIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAIN
Provider First Name:
SIDDHARTH
Provider Middle Name:
GULABCHAND
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093810632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 911230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75391-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-997-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 PRINCE GEORGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DESOTO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75115-2045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-780-0480
Provider Business Practice Location Address Fax Number:
972-780-1453
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  M9374 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 34303400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196816601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196816602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8A9487 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00615680 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01322832 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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