Provider Demographics
NPI:1932111945
Name:JAIN, JYOTI (MD)
Entity Type:Individual
Prefix:DR
First Name:JYOTI
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 CREEKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-2421
Mailing Address - Country:US
Mailing Address - Phone:972-216-8500
Mailing Address - Fax:972-216-8521
Practice Address - Street 1:6448 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-5943
Practice Address - Country:US
Practice Address - Phone:972-216-8500
Practice Address - Fax:972-216-8521
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ91102080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T52VOtherBLUE SHIELD
TX111658401Medicaid
TX75-2795302OtherTAX ID
TX00T52VOtherBLUE SHIELD