Provider Demographics
NPI:1669676060
Name:JAIN, VIBHA (MD)
Entity type:Individual
Prefix:
First Name:VIBHA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 WOLF PARK DR STE 103
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1759
Mailing Address - Country:US
Mailing Address - Phone:901-252-3400
Mailing Address - Fax:901-763-4305
Practice Address - Street 1:1325 WOLF PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1759
Practice Address - Country:US
Practice Address - Phone:901-252-3400
Practice Address - Fax:901-763-4305
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43624207ZP0102X
KY40092207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200949400Medicaid
IN01066918AOtherSTATE LICENSURE
KY40092OtherMEDICAL LICENSURE
KY1165026Medicare PIN
KY40092OtherMEDICAL LICENSURE
IN122620EMedicare PIN