Provider Demographics
NPI:1457500779
Name:JAIN, AMITA (MD)
Entity Type:Individual
Prefix:
First Name:AMITA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9339 GENESEE AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2196
Mailing Address - Country:US
Mailing Address - Phone:858-455-7520
Mailing Address - Fax:858-554-1312
Practice Address - Street 1:9339 GENESEE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2119
Practice Address - Country:US
Practice Address - Phone:858-455-7520
Practice Address - Fax:858-455-5461
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103235207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
33-0627190OtherTAX ID
BE530YMedicare PIN