Provider Demographics
NPI:1558508176
Name:JAIN, VIKAS (MD)
Entity Type:Individual
Prefix:
First Name:VIKAS
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 1:1107 MEMORIAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8662
Mailing Address - Country:US
Mailing Address - Phone:706-529-3072
Mailing Address - Fax:706-529-3077
Practice Address - Street 1:1107 MEMORIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-529-3072
Practice Address - Fax:706-529-3077
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51693207RP1001X
GA83997207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ008804Medicaid