Provider Demographics
NPI:1568436004
Name:JAIN, RAJIV (MD)
Entity Type:Individual
Prefix:
First Name:RAJIV
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 1:1491 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1234
Mailing Address - Country:US
Mailing Address - Phone:716-332-4476
Mailing Address - Fax:
Practice Address - Street 1:1491 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14217-1234
Practice Address - Country:US
Practice Address - Phone:716-332-4476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221199207R00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02165277Medicaid
NYH16701Medicare UPIN
NYRA1035Medicare ID - Type Unspecified