Provider Demographics
NPI:1841578994
Name:JAIN, ANSHUL (MD)
Entity Type:Individual
Prefix:
First Name:ANSHUL
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 1:4325 WILLIAMS BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404
Mailing Address - Country:US
Mailing Address - Phone:319-368-8400
Mailing Address - Fax:
Practice Address - Street 1:4325 WILLIAMS BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404
Practice Address - Country:US
Practice Address - Phone:319-368-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-41170207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP01371927OtherRR MEDICARE
IAP01371927OtherRR MEDICARE
IA1841578994Medicaid