Provider Demographics
NPI:1871672113
Name:JAIN, DHARAM P (MD)
Entity Type:Individual
Prefix:
First Name:DHARAM
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 1:402 W. LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-0040
Mailing Address - Country:US
Mailing Address - Phone:608-339-3331
Mailing Address - Fax:
Practice Address - Street 1:2311 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4445
Practice Address - Country:US
Practice Address - Phone:414-319-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21732207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30198800Medicaid
WIB53820Medicare UPIN