Provider Demographics
NPI:1013203082
Name:JAIN, DEEPALI (MD)
Entity type:Individual
Prefix:DR
First Name:DEEPALI
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 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-3443
Mailing Address - Fax:855-287-1988
Practice Address - Street 1:350 SEYMOUR AVE STE 2
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1336
Practice Address - Country:US
Practice Address - Phone:203-732-3443
Practice Address - Fax:855-287-1988
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT78280208600000X
WAMD60779039208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2087508Medicaid