Healthcare Provider Details

I. General information

NPI: 1528646593
Provider Name (Legal Business Name): SAMKIT JAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 08/30/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAS TABLAS RD
TEMPLETON CA
93465-9704
US

IV. Provider business mailing address

7901 BROADWAY
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-3500
  • Fax:
Mailing address:
  • Phone: 718-334-1141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA195557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: