Provider Demographics
NPI:1295980134
Name:DAVE JAIN D.O.P.C.
Entity type:Organization
Organization Name:DAVE JAIN D.O.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-888-4226
Mailing Address - Street 1:201 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2450
Mailing Address - Country:US
Mailing Address - Phone:573-888-4226
Mailing Address - Fax:573-888-4221
Practice Address - Street 1:201 FLOYD ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2450
Practice Address - Country:US
Practice Address - Phone:573-888-4226
Practice Address - Fax:573-888-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1K93207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242974426Medicaid
MO242974426Medicaid
000008931Medicare PIN