Basic Information
Provider Information | |||||||||
NPI: | 1265480784 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAIN | ||||||||
FirstName: | DIWAKAR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 WOODS RD | ||||||||
Address2: | TCC- RM D368 | ||||||||
City: | VALHALLA | ||||||||
State: | NY | ||||||||
PostalCode: | 105951530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9144937530 | ||||||||
FaxNumber: | 9144935827 | ||||||||
Practice Location | |||||||||
Address1: | 19 BRADHURST AVE | ||||||||
Address2: |   | ||||||||
City: | HAWTHORNE | ||||||||
State: | NY | ||||||||
PostalCode: | 105322140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149096900 | ||||||||
FaxNumber: | 9144932828 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 12/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | 263741 | NY | Y |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207UN0901X | MD072624L | PA | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | MD072624L | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 263741 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 001829590 | 05 | PA |   | MEDICAID | 263741 | 01 | NY | NY M.D. LICENSE | OTHER |