Provider Demographics
NPI:1932255312
Name:JAIN, MANISHA (MD)
Entity Type:Individual
Prefix:
First Name:MANISHA
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:PO BOX 90039
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9039
Mailing Address - Country:US
Mailing Address - Phone:270-796-8000
Mailing Address - Fax:270-796-8000
Practice Address - Street 1:427 US 31W BYP
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1703
Practice Address - Country:US
Practice Address - Phone:270-796-8000
Practice Address - Fax:270-796-8000
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45475207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45475OtherLICENSE
KY7100230230Medicaid