Provider Demographics
NPI:1013972769
Name:JAIN, KRISHNA MOHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:MOHAN
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 1:1815 HENSON AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1510
Mailing Address - Country:US
Mailing Address - Phone:269-492-6500
Mailing Address - Fax:269-492-6461
Practice Address - Street 1:1815 HENSON AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1510
Practice Address - Country:US
Practice Address - Phone:269-492-6500
Practice Address - Fax:269-492-6461
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010435792086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI341660510Medicaid
MI1013972769Medicaid
MI4309785OtherAETNA
MI3733063OtherPHP
MI1417961137OtherBCBSM - BMH
MIP53787OtherBLUE CARE NETWORK PROVIDE
D83153Medicare UPIN
MIC97618238 - BMHMedicare PIN
MI3733063OtherPHP