Provider Demographics
NPI:1447282991
Name:JAIN, MUKESH (MD)
Entity type:Individual
Prefix:MR
First Name:MUKESH
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 1:7615 CLARINGTON CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5647
Mailing Address - Country:US
Mailing Address - Phone:662-536-2500
Mailing Address - Fax:662-536-2505
Practice Address - Street 1:7615 CLARINGTON CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5647
Practice Address - Country:US
Practice Address - Phone:662-536-2500
Practice Address - Fax:662-536-2505
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25718174400000X
MS14601174400000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05128319Medicaid
MS06326035Medicaid
MSF82314Medicare UPIN
DA1878Medicare PIN
MSC02498Medicare PIN
P00029375Medicare PIN
MS05128319Medicaid
MS06326035Medicaid
F82314Medicare UPIN
TN3082865Medicare PIN