Provider Demographics
NPI:1427053024
Name:JAIN, CHANDRU (MD, PC)
Entity type:Individual
Prefix:
First Name:CHANDRU
Middle Name:
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5600
Mailing Address - Country:US
Mailing Address - Phone:732-364-6004
Mailing Address - Fax:732-364-1908
Practice Address - Street 1:1166 RIVER AVENUE
Practice Address - Street 2:STE 102
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5035
Practice Address - Country:US
Practice Address - Phone:732-364-9565
Practice Address - Fax:732-364-1908
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA058391002085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ300090996OtherRAILROAD
NJ5381002Medicaid
NJ300090996OtherRAILROAD
NJF48489Medicare UPIN