Provider Demographics
NPI:1104853787
Name:JAIN, AJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:AJAY
Middle Name:
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 1:1497 FAIR RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0822
Mailing Address - Country:US
Mailing Address - Phone:912-681-2273
Mailing Address - Fax:
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 305
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-681-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58253207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF94270Medicare UPIN