Healthcare Provider Details

I. General information

NPI: 1457500779
Provider Name (Legal Business Name): AMITA JAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9339 GENESEE AVE SUITE 220
SAN DIEGO CA
92121-2119
US

IV. Provider business mailing address

9339 GENESEE AVE STE 220
SAN DIEGO CA
92121-2196
US

V. Phone/Fax

Practice location:
  • Phone: 858-455-7520
  • Fax: 858-455-5461
Mailing address:
  • Phone: 858-455-7520
  • Fax: 858-554-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA103235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: