Basic Information
| Provider Information | |||||||||
| NPI: | 1326333626 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | JAIN | ||||||||
| FirstName: | PRACHI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 STE 101 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 EASCTCESTER RD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104691046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187324000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2011 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 153621 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 270369 | 01 | NY | MEDICAL LICENSE | OTHER |