Provider Demographics
NPI:1679505515
Name:JAIN, SAMAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMAY
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 1:450 S KITSAP BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3738
Mailing Address - Country:US
Mailing Address - Phone:360-895-8950
Mailing Address - Fax:360-830-1385
Practice Address - Street 1:450 S KITSAP BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3738
Practice Address - Country:US
Practice Address - Phone:360-895-8950
Practice Address - Fax:360-830-1385
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60771954207Q00000X, 208800000X
OH35099644208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075568Medicaid
WA2092193Medicaid
OH99644OtherLICENSE