Provider Demographics
NPI:1588847529
Name:JAIN, SIDDHARTH (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDDHARTH
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 1:411 E CHESTNUT ST # 6
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1713
Mailing Address - Country:US
Mailing Address - Phone:502-588-3650
Mailing Address - Fax:
Practice Address - Street 1:1432 S DOBSON RD STE 403
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4777
Practice Address - Country:US
Practice Address - Phone:480-412-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014012628208000000X, 2084N0402X
AZ610862084N0402X
KYC11182084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1588847529Medicaid
ILENROLLEDMedicaid