Provider Demographics
NPI:1568537355
Name:JAIN, KISHOR NATHMAL (MD)
Entity Type:Individual
Prefix:
First Name:KISHOR
Middle Name:NATHMAL
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 1:222 COLORADO AVENUE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1334
Mailing Address - Country:US
Mailing Address - Phone:815-469-2123
Mailing Address - Fax:815-469-2149
Practice Address - Street 1:222 COLORADO AVENUE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1334
Practice Address - Country:US
Practice Address - Phone:815-469-2123
Practice Address - Fax:815-469-2149
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
649420OtherMEDICARE PROV NUMBER
IL09915014OtherBLUE CROSS BLUE SHIELD
C41003Medicare UPIN
IL09915014OtherBLUE CROSS BLUE SHIELD