1235208018 NPI number — DR. KAMLA TERESE JAIN MD

Table of content: DR. KAMLA TERESE JAIN MD (NPI 1235208018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235208018 NPI number — DR. KAMLA TERESE JAIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAIN
Provider First Name:
KAMLA
Provider Middle Name:
TERESE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1235208018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ASU STUDENT HEALTH CENTER
Provider Second Line Business Mailing Address:
614 HOWARD STREET, MILES ANNAS BLDG
Provider Business Mailing Address City Name:
BOONE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-446-2360
Provider Business Mailing Address Fax Number:
704-366-3746

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 S SHARON AMITY RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28211-2978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-446-2360
Provider Business Practice Location Address Fax Number:
704-366-3746
Provider Enumeration Date:
11/07/2006

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: 207Q00000X , with the licence number:  200000471 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2000-00471 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6833648 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8912545 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0106165 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 12545 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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