Provider Demographics
NPI:1740203686
Name:JAIN, SURESH P (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:P
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 1:49 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3128
Mailing Address - Country:US
Mailing Address - Phone:516-640-5669
Mailing Address - Fax:
Practice Address - Street 1:13420 JAMAICA AVE
Practice Address - Street 2:1ST FL
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-206-6742
Practice Address - Fax:718-206-8818
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240921207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1496871Medicaid
F58973Medicare UPIN
5A704Medicare ID - Type Unspecified