Provider Demographics
NPI:1316926165
Name:JAIN, KIRTI (MD)
Entity type:Individual
Prefix:
First Name:KIRTI
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4927 W POND CIR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15101 SOUTHFIELD RD
Practice Address - Street 2:STE 102
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2664
Practice Address - Country:US
Practice Address - Phone:313-935-9500
Practice Address - Fax:313-294-9416
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G18775Medicare UPIN