Provider Demographics
NPI:1114453842
Name:JAIN, SANJAY KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:KUMAR
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 1:17512 DONA MICHELLE DR STE 5
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3265
Mailing Address - Country:US
Mailing Address - Phone:813-586-7600
Mailing Address - Fax:813-605-6062
Practice Address - Street 1:17512 DONA MICHELLE DR STE 5
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3265
Practice Address - Country:US
Practice Address - Phone:813-586-7600
Practice Address - Fax:813-605-6062
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.148377207Q00000X
FLME139042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107331400Medicaid