Provider Demographics
NPI:1912029190
Name:JAIN, BHAWNA
Entity Type:Individual
Prefix:
First Name:BHAWNA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30166 INDUSTRIAL PKWY SW
Mailing Address - Street 2:#272
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-6906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1418
Practice Address - Country:US
Practice Address - Phone:415-485-3524
Practice Address - Fax:415-485-3507
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68306207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA68306OtherPPIN
CAH29718Medicare UPIN