Provider Demographics
NPI:1497749238
Name:JAIN, SUSHIL (MD)
Entity Type:Individual
Prefix:
First Name:SUSHIL
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:833-724-8326
Practice Address - Fax:260-425-6845
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058235207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH061794Medicaid
OH0617943OtherOH MEDICAID MOLINA
OH310917085202OtherOH MEDICAID CARESOURCE
OH000000263296OtherOH MEDICAID UNISON
WV3810014440Medicaid
OH310917085202OtherOH MEDICAID CARESOURCE
OH0580166Medicare PIN