Provider Demographics
NPI:1285620369
Name:JAIN, MANOJ (MD)
Entity type:Individual
Prefix:
First Name:MANOJ
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:314 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1215
Practice Address - Country:US
Practice Address - Phone:410-641-0277
Practice Address - Fax:410-641-9581
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD608182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403688301Medicaid
MD403688300Medicaid
VI010040493Medicaid
DE01219116OtherAMERIGROUP PROV. # (KATIN)
VI010040523Medicaid
VI010040825Medicaid
DE1000024706Medicaid
MD10236764OtherAMERIGROUP PROV. # (BERLIN)
MD649LH342Medicare PIN
MD10236764OtherAMERIGROUP PROV. # (BERLIN)
MD403688301Medicaid