Healthcare Provider Details

I. General information

NPI: 1497749238
Provider Name (Legal Business Name): SUSHIL JAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 PARKVIEW CIRCLE DR
FORT WAYNE IN
46845
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 833-724-8326
  • Fax: 260-425-6845
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01058235
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: