Provider Demographics
NPI:1114989290
Name:JAIN, MAMTA K (MD MPH)
Entity Type:Individual
Prefix:MRS
First Name:MAMTA
Middle Name:K
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:MAMTA
Other - Middle Name:
Other - Last Name:KHANDELWAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-0624
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-0624
Practice Address - Fax:214-645-0078
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2936207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152639401Medicaid
TX152639401Medicaid
TX8813B8Medicare ID - Type Unspecified