Provider Demographics
NPI:1265480784
Name:JAIN, DIWAKAR (MD)
Entity type:Individual
Prefix:DR
First Name:DIWAKAR
Middle Name:
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 WOODS RD
Mailing Address - Street 2:TCC- RM D368
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1530
Mailing Address - Country:US
Mailing Address - Phone:914-493-7530
Mailing Address - Fax:914-493-5827
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-909-6900
Practice Address - Fax:914-493-2828
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263741207UN0901X, 207RC0000X
PAMD072624L207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001829590Medicaid
NY263741OtherNY M.D. LICENSE
PA001829590Medicaid
PA045398Medicare PIN