Provider Demographics
NPI:1063455780
Name:JAIN, SANJAY K (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:K
Last Name:JAIN
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:PANTHER VALLEY MALL, BLDG B, ROUTE 517
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840
Mailing Address - Country:US
Mailing Address - Phone:908-852-0107
Mailing Address - Fax:908-850-9160
Practice Address - Street 1:PANTHER VALLEY MALL, BLDG B, ROUTE 517
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840
Practice Address - Country:US
Practice Address - Phone:908-852-0107
Practice Address - Fax:908-850-9160
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA42351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1975102Medicaid
NY00918130Medicaid
1K1812OtherCOMMERCIAL
D19366Medicare UPIN
641490Medicare ID - Type Unspecified