Provider Demographics
NPI:1578504817
Name:JAIN, SANJAY K (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:K
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 1:2903 MEADOW FARMS PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5610
Mailing Address - Country:US
Mailing Address - Phone:502-244-3830
Mailing Address - Fax:502-426-8272
Practice Address - Street 1:4402 CHURCHMAN AVE STE 408
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-3102
Practice Address - Country:US
Practice Address - Phone:502-212-7511
Practice Address - Fax:502-426-7282
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33212207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64880255Medicaid
KYP00424387OtherRAILROAD MEDICARE - KY
KY0609050Medicare ID - Type Unspecified
KY64880255Medicaid