Healthcare Provider Details

I. General information

NPI: 1588847529
Provider Name (Legal Business Name): SIDDHARTH JAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 S DOBSON RD STE 403
MESA AZ
85202-4777
US

IV. Provider business mailing address

411 E CHESTNUT ST # 6
LOUISVILLE KY
40202-1713
US

V. Phone/Fax

Practice location:
  • Phone: 480-412-7473
  • Fax:
Mailing address:
  • Phone: 502-588-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014012628
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number61086
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number2014012628
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberC1118
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: