Provider Demographics
NPI:1649240839
Name:JAIN, SUPARNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPARNA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SURPARNA
Other - Middle Name:
Other - Last Name:JAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4745 SUTTON PARK COURT
Mailing Address - Street 2:SUITE 701
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0257
Mailing Address - Country:US
Mailing Address - Phone:904-821-0405
Mailing Address - Fax:904-821-0468
Practice Address - Street 1:4745 SUTTON PARK COURT
Practice Address - Street 2:SUITE 701
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0257
Practice Address - Country:US
Practice Address - Phone:904-821-0405
Practice Address - Fax:904-821-0468
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3946207R00000X
FLME97369207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2773473-00Medicaid
GA479073104AMedicaid
GA479073104AMedicaid
FLP00706723Medicare PIN
AR5N429Medicare ID - Type Unspecified
FL2773473-00Medicaid