Basic Information
| Provider Information | |||||||||
| NPI: | 1043552706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | AMIT | ||||||||
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| Credential: | M.D., M.B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6206 W. BELL RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808824545 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6206 W BELL RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853083750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808824545 | ||||||||
| FaxNumber: | 6028635851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | LL2445 | NV | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 54746 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | LL2445 | 01 | NV | MEDICAL RESIDENT STUDENT LICENSE | OTHER | 54746 | 01 | AZ | ARIZONA MD LICENSE | OTHER | A148127 | 01 | CA | CA PHYSICIAN AND SURGEON LICENSE | OTHER |