Provider Demographics
NPI:1538147152
Name:JAIN, SUSHIL KUMAR (MD)
Entity type:Individual
Prefix:
First Name:SUSHIL
Middle Name:KUMAR
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 VICTOR DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2666
Mailing Address - Country:US
Mailing Address - Phone:330-723-3338
Mailing Address - Fax:330-722-5439
Practice Address - Street 1:5041 VICTOR DR
Practice Address - Street 2:UNIT C
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2666
Practice Address - Country:US
Practice Address - Phone:330-723-3338
Practice Address - Fax:330-722-5439
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35067447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000139189OtherANTHEM BCBS
OH128219100OtherDEPT OF LABOR
FL913629100Medicaid
OH0145499Medicaid
OH509460001OtherCARESOURCE BWC
OH0145499Medicaid
FL913629100Medicaid