=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093810632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIDDHARTH GULABCHAND JAIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 08/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2705 PRINCE GEORGE AVE
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-780-0480
-----------------------------------------------------
Fax | 972-780-1453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 911230
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75391-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-997-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | M9374
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------