Provider Demographics
NPI:1255404471
Name:JAIN, PAWANKUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:PAWANKUMAR
Middle Name:
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2455 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5049
Mailing Address - Country:US
Mailing Address - Phone:505-522-5559
Mailing Address - Fax:505-522-5561
Practice Address - Street 1:2455 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5049
Practice Address - Country:US
Practice Address - Phone:505-522-5559
Practice Address - Fax:505-522-5561
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM99562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG69284Medicare UPIN