Provider Demographics
NPI:1851437776
Name:JAIN, VIVANTI N (MD)
Entity Type:Individual
Prefix:
First Name:VIVANTI
Middle Name:N
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2021 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE #408-E
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2208
Mailing Address - Country:US
Mailing Address - Phone:310-315-9522
Mailing Address - Fax:310-315-9542
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:SUITE #408-E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2208
Practice Address - Country:US
Practice Address - Phone:310-315-9522
Practice Address - Fax:310-315-9542
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CAG79793208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G35796Medicare UPIN