Provider Demographics
NPI:1033206420
Name:JAIN, NIDHI (MD)
Entity Type:Individual
Prefix:
First Name:NIDHI
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11220 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1814
Mailing Address - Country:US
Mailing Address - Phone:718-554-6600
Mailing Address - Fax:530-751-1237
Practice Address - Street 1:11220 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1814
Practice Address - Country:US
Practice Address - Phone:718-554-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC061109207Q00000X
CAA109318207Q00000X
NY291378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432702699Medicaid