Provider Demographics
NPI:1144274952
Name:JAIN, VIPIN K (MD)
Entity type:Individual
Prefix:
First Name:VIPIN
Middle Name:K
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1441 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5613
Mailing Address - Country:US
Mailing Address - Phone:618-532-9050
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:2920 VETERANS PARKWAY
Practice Address - Street 2:MT VERNON COMMUNITY HEALTH CENTER
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-244-6544
Practice Address - Fax:618-244-6577
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036114716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2521435Medicaid
H94646Medicare UPIN