Provider Demographics
NPI:1225080658
Name:JAIN, VIVEK (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVEK
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 1:310 N L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1300
Mailing Address - Country:US
Mailing Address - Phone:270-651-1111
Mailing Address - Fax:270-659-5856
Practice Address - Street 1:310 N L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1300
Practice Address - Country:US
Practice Address - Phone:270-651-1111
Practice Address - Fax:270-659-5856
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37568174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64063043Medicaid
KY64063043Medicaid