Provider Demographics
NPI:1336417039
Name:JYOTI JAIN, MD, PA
Entity Type:Organization
Organization Name:JYOTI JAIN, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JYOTI
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:972-216-8500
Mailing Address - Street 1:6448 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-5943
Mailing Address - Country:US
Mailing Address - Phone:972-216-8500
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9110208000000X, 2080A0000X
TX717114363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX717114OtherNICOLE LICENSE
TX111658401OtherDR JAIN TPI
1508151994OtherNICOLE NPI
TXJ9110OtherDR JAIN LICENSE
1932111945OtherDR JAIN NPI
TX717114OtherNICOLE LICENSE