Provider Demographics
NPI:1093810632
Name:JAIN, SIDDHARTH GULABCHAND (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDDHARTH
Middle Name:GULABCHAND
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:
Practice Address - Street 1:2705 PRINCE GEORGE AVE
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2045
Practice Address - Country:US
Practice Address - Phone:972-780-0480
Practice Address - Fax:972-780-1453
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9374208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34303400Medicaid
TX196816601Medicaid
TX196816602Medicaid
TX8A9487OtherBLUE CROSS BLUE SHIELD
TXP00615680OtherRAILROAD MEDICARE
TXP01322832OtherRAILROAD MEDICARE
TX8A9487OtherBLUE CROSS BLUE SHIELD
H37246Medicare UPIN
VI344817YM09Medicare PIN
TXTXB105127Medicare PIN
TXP00615680OtherRAILROAD MEDICARE