Provider Demographics
NPI:1356305601
Name:JAIN, MUDIT (MD)
Entity Type:Individual
Prefix:DR
First Name:MUDIT
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 1:300 NW 70TH AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2384
Mailing Address - Country:US
Mailing Address - Phone:954-585-6292
Mailing Address - Fax:
Practice Address - Street 1:300 NW 70TH AVE
Practice Address - Street 2:STE 105
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2384
Practice Address - Country:US
Practice Address - Phone:954-585-6292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75960207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG44126Medicare UPIN