Provider Demographics
NPI:1730408121
Name:JAIN, PRANJAL (MD)
Entity type:Individual
Prefix:
First Name:PRANJAL
Middle Name:
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 1:409 BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2707
Mailing Address - Country:US
Mailing Address - Phone:813-844-5470
Mailing Address - Fax:
Practice Address - Street 1:12662 TELECOM DR
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0935
Practice Address - Country:US
Practice Address - Phone:813-910-8708
Practice Address - Fax:855-852-7153
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121344207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014122500Medicaid
FL014122500Medicaid