Provider Demographics
NPI:1952615239
Name:JAIN, NITASHA GARG (MD)
Entity Type:Individual
Prefix:DR
First Name:NITASHA
Middle Name:GARG
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NITASHA
Other - Middle Name:
Other - Last Name:GARG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6320 RIVERSIDE PLAZA LN NW STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1710
Mailing Address - Country:US
Mailing Address - Phone:505-843-6168
Mailing Address - Fax:505-792-1978
Practice Address - Street 1:1001 COAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-843-6168
Practice Address - Fax:505-792-1978
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097186207V00000X
NMMD2018-0663207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2018-0663OtherNM MD